
Class ~1f?X^ 
Book__iV_3 . 



ill 



fopyrigM^?-. 



COPYRIGHT DEPOSIT, 



A TEXT-BOOK 



ON 



MINOR SURGERY 



BY 

JOHN C. VAUGHAN, M.D. 

DIRECTOR AND VISITING SURGEON BEEKMAN STREET HOSPITAL; VISITING SURGEON SING 

SING PRISON HOSPITAL; CONSULTING SURGEON MANHATTAN EYE AND EAR HOSPITAL; 

CONSULTING SURGEON WORKERS* HEALTH BUREAU; FORMER VISITING SURGEON 

BELLEVUE HOSPITAL AND CHIEF VANDERBILT SURGICAL CLINIC AND 

INSTRUCTOR IN MINOR SURGERY COLUMBIA MEDICAL COLLEGE 

AND 

ATHEL CAMPBELL BURNHAM, M.D. 

COLONEL IN UNITED STATES ARMY; IN CHARGE OF THE MEDICAL DEPARTMENT OF RED 

CROSS IN POLAND; ATTENDING SURGEON VOLUNTEER HOSPITAL; FORMER ATTENDING 

SURGEON DEPARTMENT OF SURGERY, VANDERBILT CLINIC, COLLEGE OF 

PHYSICIANS AND SURGEONS; FORMER INSTRUCTOR IN SURGERY IN 

THE POLYCLINIC HOSPITAL 



ILLUSTRATED WITH 459 ENGRAVINGS 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1922 



PREFACE. 



During the last decade while surgery has shared in the great advance 
made by all the sciences, one of its branches, minor surgery, has far 
outstripped the others. This has been caused by a great number of 
factors. The industrial clinic, the workers compensation insurance, 
the use of local anesthesia, and the realization of the far-reaching 
results and complications of poorly and improperly treated minor 
injuries have been responsible for the prodigious strides of this branch. 
The disfiguring scars of burns, the stiff fingers, due to neglected tendon 
sheath infections, and other such conditions so important to the indi- 
vidual both socially and economically have left their indelible imprint 
upon all surgeons, stimulating them to a keener interest in this formerly 
unimportant division of surgery. 

To give detailed description of the widely different methods of 
treating the same surgical condition would fill many volumes, and 
would fall far beyond the scope of this book. In the chapters which 
follow an attempt has been made to give those surgical procedures 
which are simple and efficient. In their selection it has always been 
borne in mind that while complicated treatments may yield better 
results in the hands of their originators, complete failure has often met 
the attempts of those not skilled in the involved technic. 

A work on Surgery has long since ceased to be the product of an indi- 
vidual. We, therefore, extend our heartiest thanks to other authors, 
our predecessors and teachers; and for much help to Doctors G. M. 
Phelps and Ralph Colp, and also to Grace Adams and Emma Renick. 

J. C. V. 

A. C. B. 

New York, 1922. 



CONTENTS. 



CHAPTER I. 



General Injuries to the Soft Parts. 

Abrasions 17 

Contusions ' 18 

Hematoma of the Soft Parts 19 

Wounds of the Soft Parts . " 20 

Prevention of Infection 20 

Control of Hemorrhage ' 21 

Suture of Wounds ' 22 

Drainage 26 

Dressings. 27 

Suppurating Wounds . 28 

Puncture Wounds . 28 

Contused Wounds 29 

Lacerated Wounds 29 

Subcutaneous Injuries to the Soft Parts 29 

Rupture of Muscle or Strain 30 

Rupture of Tendons 30 

Rupture of the Bloodvessels 30 

Rupture of Nerves 32 

Burns and Scalds 32 

Sunburn 36 

Effects of Intense Cold 36 

Chilblains 36 

Frost-bite 37 

Frost-bite of the Abdominal Wall 38 

Specific Infections 38 

Erysipelas 39 

Tetanus 39 

Anthrax 40 

Hydrophobia . 41 

CHAPTER II. 

Fractures in General. 

Symptoms 42 

Special Varieties of Fractures 49 

Separation of the Epiphyses 49 

Greenstick Fractures 50 

Spontaneous Fractures 50 

The Treatment of Fractures • 50 

Temporary Treatment 51 

Reduction 51 

Retention of Fractures -.-.•.. . . . . . 51 

Restoration of Function 58 

Complications of Fractures 59 

Compound Fractures 59 

Hemarthrosis and Traumatic Arthritis 60 

Hematoma . . 60 

Paralysis 60 



vm CONTENTS 

Complications of Fractures — 

Ischemic Contraction 60 

Stiffness of the Muscles 61 

Thrombosis and Embolism 61 

Delayed Union 61 

Faulty Union 62 

Roentgenographic Control 63 

CHAPTER III. 

Injuries to Joints. 

Dislocations 64 

Complications of Dislocations 68 

Fracture 68 

Injury to the Bloodvessels 68 

Habitual Dislocation 68 

Compound Dislocation 69 

Subluxation 69 

Treatment of Dislocation . 69 

Reduction 69 

Retention 70 

Restoration of Function 72 

Old Dislocations 72 

Congenital Dislocations 72 

Sprains 72 

Sprain-fracture . 75 

Traumatic Synovitis 75 

Wounds of the Joints 77 

Gunshot Wounds 79 



CHAPTER IV. 

Inflammation, Suppuration and Gangrene. 

Inflammation 81 

Infected Wounds 87 

Cellulitis 96 

Acute Abscess 99 

Gangrene 102 

Senile Gangrene 105 

Raynaud's Disease 106 

Diabetic Gangrene 106 

Gangrene from Ergot Poisoning . . . . 106 

Phenol Gangrene 106 

Bed-sore or Decubital Gangrene 107 

Noma 108 

Gas Gangrene 108 

CHAPTER V. 

Injuries to the Head. 

Abrasion of the Face and Scalp 110 

Contusions of the Scalp 110 

Hematoma of the Scalp Ill 

Hematoma in the New-born 113 

Contusions of the Face 114 

Contusion of the Eye 114 

Contusion of the Ear 115 

Contusion of the Nose 115 

Foreign Bodies in the Head and Face 117 

Powder Grains in the Skin 117 

Foreign Body in the Eye .... 118 



CONTENTS ix 

Foreign Bodies in the Head and Face — ■ 

Foreign Bodies in tjie Ear 119 

Foreign Bodies in the Nose 119 

Foreign Bodies in the Mouth and Throat 119 

Foreign Body in the Larynx or Trachea 120 

Wounds of the Head and Face 120 

Wounds of the Scalp 121 

Wounds of the Face 122 

Wounds of the Mouth 122 

Wounds of the Eye, Nose and Ear 123 

Burns of the Head and Face 123 

Burns of the Mouth 124 

Burns of the Eyes . 124 

Chemical Burns of the Face 124 

"Mustard Gas" Burns 125 

Fracture of the Skull 125 

Fractures about the Face 1 28 

Fracture of the Nose 128 

Fracture into the Frontal Sinus 129 

Fracture of the Malar Bone 129 

Fracture of the Superior Maxilla . 130 

Fracture of the Zygomatic Arch 130 

Fracture of the Mandible 130 

Dislocation of the Mandible 132 

Inflammation of the Head and Scalp 133 

Simple Herpes 133 

Herpes Zoster 133 

Impetigo Contagiosa 134 

Septic Infections of the Face and Scalp 134 

Boils and Furuncles 134 

Sty or Hordeolum 136 

Carbuncle 137 

Cellulitis 137 

Cellulitis of the Scalp 137 

Cellulitis of the Face 139 

Ringworm of the Scalp 139 

Abscesses 139 

Alveolar Abscess 139 

Peritonsillar Abscess 142 

Retropharyngeal Abscess 143 

Suppurative Parotitis 143 

Erysipelas 144 

Anthrax 144 

Actinomycosis 145 

Glanders 145 

Syphilis "... 146 

Primary Lesion 146 

Secondary Lesions 147 

Tertiary Lesions 147 

Tuberculosis 148 

Lupus Vulgaris 148 

Tuberculous Ulcers 150 

Benign Tumors of the Head 150 

Moles 150 

Papilloma or Warts 151 

Angioma 151 

Sebaceous Cysts 152 

Dermoid Cyst 155 

Congenital Sinus 157 

Cysts and Calculi of the Mouth 157 

Mucous Cysts 157 

Ranula 157 

Parotid Cyst 158 

Salivary Calculi 158 

Salivary Fistula .... ... 159 



X CONTENTS 

Benign Tumors of the Face . . . : . . . 159 

Lipoma . . . . . , . . . 159 

Osteoma 160 

Fibroma 161 

Cutaneous Horn 161 

Malignant Tumors of the Head and Face ■ 162 

Epithelioma - 163 

Superficial Epithelioma 163 

Deep-seated Epithelioma . . 164 

Papillary Epithelioma 165 

Epithelioma of the Lip . . 166 

Epithelioma of the Tongue 168 

Sarcoma of the Face 169 

Epulis 170 

Parotid Tumors 170 

Plastic Surgery of the Face 170 

Disfiguring Scars . 172 

Ectropion 172 

Plastic Operations on the Nose 173 

Partial Loss of Ala or Tip 173 

Loss of Cartilaginous Portion 174 

Loss of Bridge of Nose 174 

Harelip ■ 174 

Tongue-tie 175 

Cleft Palate 175 

Plastic Surgery of the External Ear . . . . . 170 

Colomba 176 

Macrotia, or Enlargement of External Ear 176 

Auricular Appendages 177 

Malposition of the Ear 177 

Deformities of the Cheeks . .177 

CHAPTER VI. 

Injuries and Inflammations of the Neck. 

Wounds of the Neck 178 

Wounds of the Trachea . . . . . . . 178 

Tracheotomy 179 

Intubation 181 

Wounds of the Esophagus 181 

Contusions of the Neck 181 

Sprains of the Neck 182 

Burns of the Neck 182 

Septic Infection of the Neck 182 

Cellulitis 182 

Boils . * 183 

Carbuncle of the Neck 184 

Abscess of the Neck 186 

Angina Ludovici 187 

Diseases of the Cervical Lymph Nodes . . ... 187 

Acute Lymphadenitis 187 

Chronic Lymphadenitis 189 

Tuberculosis of the Cervical Lymph Nodes 191 

Fractures and Dislocations of the Neck 198 

Fractures of the Cervical Vertebrae 198 

Dislocation of the Cervical Vertebrse 199 

Fracture of the Hyoid Bone 200 

Fracture of the Larynx 200 

Fracture of the Trachea 201 

Tumors of the Neck " 201 

Hair Cysts 201 

Branchial Cysts 201 

Hygroma 202 

Thyroglossal Cysts ... 203 

Tumors of the Thyroid Gland .203 

Lipoma 206 



CONTENTS xi 



CHAPTER VII. 

Special Surgical Conditions of the Trunk. 

Contusions of the Trunk 208 

Contusions of the Chest 208 

Contusion of the Abdomen 209 

Wounds of the Trunk 211 

Wounds of the Chest 211 

Wounds of the Abdomen 211 

Sprain of Back 212 

Herpes Zoster 214 

Minor Operations for Pleurisy and Empyema 215 

Exploratory Puncture 215 

Aspiration of the Chest 215 

Minor Operations for Empyema 217 

Surgical Conditions of the Breast 219 

Abscess of the Breast 219 

Chronic Lobular Mastitis 222 

Tuberculosis of the Mammary Gland 222 

Tumors of the Nipple • 223 

Benign Tumors of the Breast 224 

Hypertrophy of the Breast 225 

Tuberculosis of the Region of the Trunk 225 

Tuberculosis of the Ribs . 226 

Aspiration of a Cold Abscess 228 

Tuberculosis of the Lymph Nodes 228 

Artificial Pneumothorax 229 

Surgical Disease of the Umbilicus 229 

Hemorrhage 229 

Umbilical Hernia 229 

Umbilical Sinus 230 

Suppuration of the Umbilicus 231 

Tumors of the Trunk 232 

Keloid 232 

Desmoid 235 

Epiplocele 235 

Cystic Growths 236 

Fractures and Dislocations of the Trunk 237 

Fracture of the Clavicle 237 

Fracture of the Sternum 240 

Fractures of the Ribs 241 

Fracture of the Costal Cartilages 243 

Fracture of the Vertebrae 244 

Fracture of the Pelvis . . 244 

Fracture of the Crest of the Ilium 244 

Fracture of the Spinous Process of the Ilium 245 

Fracture of the Coccyx 245 

Dislocation of the Clavicle 245 

Dislocation of the Costal Cartilage 246 

Dislocation of the Sternum 246 

Dislocation of the Coccyx 246 



CHAPTER VIII. 

Fractures and Dislocations of the Hand and Arm. 

Fractures about the Shoulder 247 

Fracture of the Coracoid 247 

Fracture of the Acromion 247 

Fracture of the Body of the Scapula 247 

Fracture of the Neck of the Scapula 248 



xil CONTENTS 

Fracture of the Humerus 248 

Fracture of the Greater Tuberosity 248 

Fractures of the Surgical Neck of the Humerus 249 

Fracture of the Shaft of the Humerus 251 

Fractures of the Lower Extremity of the Humerus 251 

Separation of the Lower Epiphysis of the Humerus 254 

Fracture of the Olecranon ....'..... 254 

Fracture of the Coronoid Process 255 

Fracture of the Head of the Radius 256 

Fracture of the Bones of the Forearm 256 

Fractures of the Forearm in Children 259 

Epiphyseal Sprain 261 

Colles' Fracture 261 

Chauffeur's Fracture of the Radius 264 

Fractures of the Carpus 267 

Scaphoid 267 

Fractures of the Semilunar and Os Magnum 268 

Fracture of the Metacarpals 268 

Fracture of the Phalanges . • 271 

Fracture of the Sesamoid Bones 274 

Dislocations of the Shoulder 274 

Dislocation of the Elbow 277 

Subluxation of the Head of the Radius . 280 

Dislocation of the Wrist 280 

Dislocation of the Carpal Bones 280 

Dislocation of the Semilunar 280 

Dislocation of the Metacarpal Bones 281 

Dislocation of the Thumb 281 

Dislocation of the Phalanges 282 

Dislocation of the Thumb 282 

Dislocation of the Fingers 283 



CHAPTER IX. 

Injuries of the Arm and Hand. 

Contusions of the Arm and Hand 286 

Wounds of the Arm and Hand ' 286 

Blank-cartridge Wounds 288 

Nerve Injuries 289 

Muscle Injuries 291 

Wounds of Muscles . 291 

Muscle Strain . 291 

Rupture of Biceps Muscle , 292 

Rupture of the Triceps Tendon 293 

Rupture of the Long Extensor of the Thumb 293 

Wounds of Tendons 293 

Dislocations of Tendons 294 

Traumatic Synovitis 294 

Mallet-finger . 295 

Crushing Injuries of the Fingers 295 

Fracture of the Nail 296 

Subungual Hemorrhage 297 

Lacerated and Compound Fracture of Finger Tip 298 

Traumatic Amputation of the Fingers 299 

Extensive Crushing of the Fingers . 299 

CHAPTER X. 

Acute Infections of the Upper Extremity. 

Erysipelas and Erysipeloid 303 

Erysipeloid • 303 



CONTENTS xiii 

Ringworm (Trichophytosis) 304 

RingY^orm of Nails (Trichophytosis Unguium 304 

Pyogenic Infection of the Upper Extremity 305 

Lymphangitis of the Hand 306 

Cellulitis 306 

Abscess of the Hand 314 

Suppurative Tenosynovitis 314 

Arthritis .... 319 

Suppurative Arthritis 319 

Osteomyelitis 320 

Osteomyelitis of the Hand 320 

Special Infections, of the Upper Extremity 321 

Cellulitis of the End of the Fingers (Felon) 321 

Paronychia 323 

Cellulitis of the Interdigital Web 323 

Infection of the Hair Follicles 324 

Cellulitis of the Forearm 325 

Supracondylar Abscess . . . . • 326 

Abscess of the Axilla 326 

CHAPTER XI. 

Miscellaneous Affections of the Hand and Arm. 

Bursitis 328 

Subdeltoid Bursitis . . 328 

Olecranon Bursitis 330 

Arthritis 332 

Arthritis of the Fingers 332 

Gonorrheal Arthritis 332 

Gouty Deposit 334 

Tuberculosis of the Arm and Hand 334 

Tuberculous Arthritis 334 

Tuberculosis of the Tendon Sheaths 334 

Non-tuberculous Tenosynovitis 335 

Tuberculosis of the Phalanges (Spina Ventosa) 336 

Syphilis of the Hand and Arm 338 

Syphilitic Dactylitis 339 

CHAPTER XII. 
Tumors and Deformities of the Arm and Hand. 

Benign Tumors of the Arm and Hand . . . .- . . ... . . 340 

Neuroma . 340 

Neurofibroma 340 

Fibroma 340 

Lipoma 341 

Hygroma 342 

Sebaceous Cyst 343 

Papilloma 343 

Osteoma 344 

Ganglion 344 

Synovial Warts 346 

Malignant Tumors of the Arm and Hand . . 347 

Carcinoma 347 

Sarcoma 348 

Congenital Deformities of the Arm and Hand 349 

Polydactylism 349 

Syndactylism 350 

Acquired Deformities of the Arm and Hand 352 

Dupuytren's Contraction 352 

Cicatricial Contraction 354 

Ischemic Muscular Paralysis 355 

Deformities Secondary to Nerve Injury 357 



xiv CONTENTS 

CHAPTER XIII. 

Fractures and Dislocations of the Lower Extremity. 

Minor Fractures of the Thigh 359 

Fracture of the Neck of the Femur 359 

Fracture of the Greater Tuberosity 359 

Fracture of the Lesser Trochanter 360 

Fracture of the Epicondyle 360 

Fracture of the Patella 361 

Minor Fractures of the Leg 365 

Separation of the Tubercle of the Tibia 365 

Fracture of the Fibula 366 

Fracture of the Shaft of the Fibula 366 

Fractures about the Ankle 368 

Pott's Fracture . . 368 

Fracture of the Internal Malleolus 371 

Fracture of the External Malleolus . . 372 

Oblique Fracture of the Lower End of the Tibia 372 

Minor Complaints Following Fractures about the Ankle 372 

Fractures of the Tarsus 375 

Fracture of the Astragalus 375 

Fracture of the Os Calcis 376 

Fracture of the Sustentaculum Tali . ... . . ..... ... . 376 

Fracture of the Scaphoid 376 

Fracture of the Cuboid and Cuneiforms 377 

Fractures of the Metatarsals and Phalanges . 377 

Fracture of the Metatarsals 377 

Fracture of the Phalanges 378 

Fracture of the Sesamoid Bones 379 

Minor Dislocations of the Lower Extremity 379 

Dislocation of the Patella 379 

Dislocated Meniscus 381 

Dislocations of the Fibula 382 

Dislocation of the Tarsus 382 

Subluxation of the Fourth Metatarsal 382 

Dislocation of the Toes 383 

CHAPTER XIV. 

Injuries to the Leg and Thigh. 

Hematoma 384 

Wounds of the Knee-joint 385 

Injuries to Nerves and Muscles 387 

Rupture of the Plantaris Tendon . . . . . 388 

Rupture of the Quadriceps 389 

Acute Synovitis of the Knee 390 

Chronic Synovitis of the Knee 391 

Loose Bodies in the Knee 394 

Prepatellar Bursitis 394 

Suppurative Bursitis 396 

Other Varieties of Bursitis 397 

Sprain 398 

Sprained Ankle 398 

Sprain of the Knee 399 

Sprain of the Hip ... . 399 

CHAPTER XV. 

Miscellaneous Affections of the Leg and Thigh. 

Cellulitis 400 

Lymphadenitis 400 



CONTENTS xv 

Lymphadenitis — 

Bubo 400 

Abscess of the Popliteal Space 402 

Varicose Veins 402 

Phlebitis and Thrombosis 404 

Postoperative Phlebitis 404 

Phlebitis of Varicose Veins 406 

Localized Phlebitis 406 

Chronic Ulcers of the Leg 407 

Deformities of the Legs and Thigh 412 

Bow-legs 413 

Knock-knee 413 

Tumors of the Leg 414 

Osteoma 414 

Carcinoma 415 

CHAPTER XVI. 

Minor Surgery of the Foot. 

Injuries of the Foot 416 

Sprains of the Foot . . . . . 417 

Amputation of the Toes ' 418 

Puncture Wounds of the Foot 420 

Cellulitis of the Foot 422 

Weak-foot and Flat-foot 424 

Hallux Valgus 433 

Hollow or Contracted Foot 435 

Morton's Disease • . 436 

Achillodynia 437 

Painful Heel 437 

Hammer-toe 438 

Tenosynovitis about the Ankle 438 

Ringworm of the Foot (Trichophytosis Pedis) 440 

Dermatitis of the Foot 441 

Perforating Ulcer of the Foot 441 

Gangrene of the Foot . 443 

Ingrowing Toe-nail 444 

Clavus or Corn 446 

Callosities 447 

Plantar Wart : . . 447 

Deformities of the Foot 448 

Congenital Deformities 448 

Acquired Deformities 449 

CHAPTER XVII. 

Affections of the Rectum and Anus. 

Wounds of the Rectum . 450 

Foreign Bodies in the Rectum 451 

Deformities of the Anus and Rectum 451 

Imperforate Anus 451 

Anal Fissure 453 

Hemorrhoids 453 

External Hemorrhoids 454 

Internal Hemorrhoids 455 

Dilatation of the Sphincter 456 

Intertrigo of Anus 457 

Pruritus Ani ■ 458 

Ischiorectal Abscess 458 

Fistula-in-ano 461 

Prolapse of the Rectum 465 

Polypus of the Rectum 467 

Ulcers of the Rectum and Anus 468 

Coccygeal Cysts 470 

Malignant Tumors of the Rectum and Anus 470 



xvi CONTENTS 



CHAPTER XVIII. 

Affections of the External Genitals of the Males. 

Injuries 472 

Wounds of the Penis 472 

Wounds of the Testicle . 472 

Contusions of the Penis and Testicle 472 

Hematoma 473 

Hematocele 473 

Fracture of the Penis 473 

Rupture of the Urethra 474 

Foreign Bodies in the Penis 475 

Paraphimosis 476 

Retention of Urine 476 

Burns of the External Genitalia 477 

Diseases of the Male External Genitalia 478 

Balanitis 478 

Herpes Genitalis 478 

Edema of the Penis 479 

Preputial Calculi 479 

Adhesions of the Prepuce 479 

Abscess 480 

Urethritis . 480 

Venereal Prophylaxis 480 

Epididymitis 481 

Epididymotomy 482 

Acute Orchitis 483 

Stricture of the Urethra 484 

Urinary Fistula 485 

Hydrocele 485 

Varicocele 487 

Tuberculosis 488 

Syphilis 490 

Syphilis of the Testes 490 

Deformities of External Genitals of Males 490 

Congenital Stricture of the Urethra 490 

Phimosis 492 

Hypospadias 495 

Epispadias 496 

Undescended Testicle 497 

Tumors of the Penis 498 

Cysts 498 

Papillomata 498 

Fibromata 499 

Epitheliomata of the Penis 499 

Sarcoma 500 

Tumors of the Scrotum and Testicle • 500 

Cysts 500 

Epithelioma of the Scrotum 500 

Teratoma of the Testicle 501 

Cysts of the Epididymis 501 

CHAPTER XIX. 
Gynecological Minor Surgery. 

Wounds of the Female Genitalia 503 

Hematoma of the Female Genitalia 503 

Laceration of the Perineum 504 

Varicose Veins of the Vulva 505 

Hypertrophy of the External Genitalia 506 

Adhesions Between the Labia and the Clitoris 507 

Malformations of the Vagina and Hymen 507 



CONTENTS xvn 

Vulvitis and Vaginitis 508 

Pruritus Vulvae 509 

Foreign Bodies in the Vagina and Urethra 510 

Abscess of the Vulvo-vaginal Glands 510 

Vulvo-vaginal Cyst 511 

Ulceration of the Vulva 512 

Simple Ulceration 512 

Chancroids 512 

Chancre 513 

Lupus 513 

Vaginismus 514 

Coccycodynia 514 

Benign Tumors of the Vulva and Vagina 515 

Venereal Warts . 515 

Hydrocele of the Labium 515 

Lipoma 516 

Fibroma 516 

Malignant Tumors of the Vulva and Vagina 516 

Epithelioma 516 

Sarcoma 517 

Urethral Caruncle 517 

Vaginal Cysts 517 



CHAPTER XX. 

Bandaging. 

The Roller Bandage 518 

Circular Bandages ' . 519 

Spiral Bandage 520 

Figure-of-eight Bandage 520 

Spiral Reverse Bandage 521 

Spica Bandage 521 

Recurrent Bandage 522 

Bandages of the Head and Neck 522 

The Four-tailed Bandage 522 

Circular Bandage of the Head 522 

Circular Bandage of the Neck 523 

Oblique Bandage of the Eye . 523 

Figure-of-eight Bandage of Both Eyes . 523 

Oblique Bandage of the Ear 524 

Recurrent Bandage of Head 525 

Figure-of-eight Bandage of Neck and Forehead 525 

Bandage of the Cheek 526 

Barton's Bandage 526 

Bandages of the Upper Extremity 527 

Spica of the Shoulder 527 

Figure-of-eight of the Axilla 528 

Velpeau's Bandage 528 

Desault's Three-roller Bandage 529 

Bandage of the Finger 529 

Gauntlet Bandage 530 

Demi-gauntlet Bandage 530 

Spica of the Thumb 530 

Figure-of-eight of the Elbow ' 532 

Bandages of the Lower Extremity 533 

Spica of the Groin 533 

Descending Spica 534 

Spica of the Buttock 534 

Bandage of the Thigh 535 

Bandage of the Knee 536 

Bandage of the Leg and Foot 537 

Recurrent Bandage of the Toes 539 

Recurrent Bandage of a Stump 541 



xvm CONTENTS 

Bandages of the Trunk . . . . . . 542 

Figure-of-eight Bandage of the Chest 542 

Spica Bandage of the Chest 542 

Spiral Bandage of the Abdomen 542 

Bandage of the Breast 543 

Bandage of Both Breasts . 544 

Many-tailed Bandage 544 

Abdominal Binder 545 

Binder of the Breast 545 

The Triangular Bandage 545 

Bandage of the Scalp 546 

Cravat of the Eye 546 

Bandage of the Chest 547 

Bandage of the Back 547 

Bandage of the Axilla 547 

Bandage of the Hip 547 

Bandage of the Arm 547 

Bandage of the Foot ' 547 

Broad Sling of the Arm 547 

The Handkerchief Bandage 547 

Special Bandages 548 

TheT-bandage 548 

The Two-tailed T-bandage 548 

Suspensory Bandage of the Scrotum 548 

Hammock Suspensory 548 

Four-tailed Bandage 549 

CHAPTER XXI. 

Local Anesthesia. 

Cocain 550 

Novocain 551 

Adrenalin in Local Anesthesia 552 

Methods of Application of Local Anesthesia 553 

Technic of Local Anesthesia : 555 

Technic of Operations 556 

Scalp 556 

Face 556 

Neck 558 

Local Anesthesia in Thoracotomy 558 

Blocking of the Intercostal Nerve 559 

Operations upon the Abdomen 560 

Operations upon the Penis and Scrotum 560 

Operations upon the Penis 561 

Local Anesthesia of the Anus . 561 

Operations on the Fingers 562 

Operations upon the Thumb . . . . . . .564 

Operations upon the Hand 565 

Operations on the Foot 565 

Complete Anesthesia of the Foot 566 

Sacral Anesthesia 567 

Postoperative Pain 568 

CHAPTER XXII. 

Special Minor Operations. 

Hypodermic Injections 569 

Intramuscular Injections , 569 

Intravenous Infusion 569 

The Injection of Arsphenamine 571 

Lumbar Puncture 573 

Intravenous Medication 574 



CONTENTS xix 

Paracentesis of the Abdomen 575 

Hypodermoclysis 576 

Phlebotomy 570 

Withdrawal of Blood Specimen 578 

Blood Transfusion 579 

Skin-grafting 584 

Thiersch Method 586 

Wolfe Method . 588 

CHAPTER XXIII. 

Surgical Technic and Supplies. 

The Operating Room 589 

Instruments 591 

Sutures and Ligatures 592 

Catgut 592 

Kangaroo Tendon • . 593 

Silk 593 

Linen 593 

Silkworm-gut 593 

Silver Wire 593 

Horsehair 593 

Dressings 594 

Gauze 594 

Drainage 595 

Surgical Accessories 596 

Towels 596 

Operating Gowns 596 

Adhesive Plaster 596 

Preparation of the Patient 596 

Preparation of the Surgeon's Hands 597 

Operative Technic . 597 

Anesthesia 598 

The Incision .... 599 

Ligatures 599 

Sutures . t 601 

Deep Sutures 601 

Interrupted Suture 601 

Continuous Suture 601 

Subcuticular Suture 602 

Chain Suture 602 

Mattress Suture 602 

Approximation Suture 603 

Emergency Makeshifts .,...,,,, 603 



MINOR SURGERY. 



CHAPTER I. 
GENERAL INJURIES TO THE SOFT PARTS. 

Injuries to the soft parts occupy, numerically, an exceedingly 
important position in the field of minor surgery. Probably no other 
affection or group of affections occurs as frequently in the practice of 
the general practitioner or casual surgeon as wounds of the skin and 
underlying tissues. In the first-aid station and the out-patient 
dispensary most of the emergencies which present themselves for 
treatment are wounds and associated injuries of the softer elements 
of the human body. 

The following sections will be devoted to a general discussion of 
injuries to the soft parts. Under the regional classification, only 
those injuries will be discussed which acquire special significance in 
the location under consideration. 

ABRASIONS. 

Abrasions are superficial wounds usually occurring on the exposed 
portions of the body. They are caused by the scraping away of 
the superficial layer of the skin against a roughened surface, and 
when they are the result of falls on the street they are likely to be 
contaminated with particles of dirt and grit. 

It has recently become the custom in large industrial organizations 
to insist upon adequate treatment, for even the smallest abrasion, 
or scratch, although apparently insignificant, may result in serious, 
disabling infections. 

If the scratches and small abrasions so frequently seen are painted 
at once with tincture of iodine, the total number of cases of cellulitis 
will be greatly diminished. In many cases no dressing is required. 
When there is bleeding, a protective dressing should be applied. 

Treatment. —If the abrasion contains considerable contamination it 
should be scrubbed with a stiff brush until the dirt has been removed ; 
then washed with ether if there is any grease or oil in the wound ; and 
finally painted with a weak solution of tincture of iodine (3 per cent). 
A dry dressing is then applied, and should not be removed for four 
2 



IS GENERAL INJURIES TO THE SOFT PARTS 

or five days or longer, unless there is evidence of infection. The mis- 
take is often made of removing the gauze daily, which is not only 
very painful but serves to open up new avenues for infection. A 
good plan, not only in abrasions but in other wounds as well, is to 
remove only the outer dressing when the wound is inspected, leaving 
the adherent gauze attached to the wound until it separates easily. 
The only exception to this is when the wound shows signs of infection. 
If an abrasion becomes infected it should be dressed either with 
a wet dressing or an antiseptic ointment, as described elsewhere. 
Boric acid in saturated solution serves admirably as a wet dressing; 
while boric-acid ointment usually gives excellent results in cases 
where healing is. progressing satisfactorily and the wet dressing is 
found inconvenient. 

CONTUSIONS. 

A contusion is a wound which results from a blow with a blunt 
instrument. The skin is usually unbroken, but contusions may be 
associated with abrasions. The pain is due to the accompanying 
swellings and edema which causes pressure on the nerve endings. 
Diagnosis is always made by exclusion, every contusion being a 
potential fracture, sprain or other injury to the deeper parts. If 
other injuries can be excluded the diagnosis of contusion is justified. 
Simple contusions usually resolve without complications in from 
seven to ten days. There is often considerable subcutaneous hemor- 
rhage with associated discoloration (ecchymosis). In some cases the 
ecchymosis may become evident at a considerable distance from the 
injury. Thus, contusions of the buttocks may be followed by ecchy- 
mosis on the thighs. 

In a few cases the subcutaneous injury to the tissues may be so 
severe as to interfere with the vitality of the contused area. In such 
cases infection is apt to occur either through a minute abrasion or 
through one of the numerous cutaneous follicles. 

Treatment. — If seen immediately after the injury cold compresses 
or an ice-cap may be applied and moderate pressure made upon the 
injured part, with the object of limiting the intercellular exudation. 
Later, when exudation has taken place, heat may be applied and 
gentle massage given in the direction of the lymph flow, in order to 
cause the absorption of the extravasated serum and blood. 

A wet dressing, possibly because it causes dilatation of the vessels, 
acts favorably in the diminution of the swelling. This is in contra- 
diction to the frequently expressed belief that a wet dressing serves 
only as a medium for drainage and is only of value when there is an 
open wound. If the pain is very severe hot stupes or even dry heat 
may be applied. Flaxseed poultices, or some other form of moist 
poultice, are most effective in relieving pain and hastening absorption. 



HEMATOMA OF THE SOFT PARTS 



19 



HEMATOMA OF THE SOFT PARTS 

Occasionally following an injury, usually a contusion, there is a 
considerable hemorrhage beneath the skin which, instead of spread- 




Fig. 1. — Old organized hematoma of groin following strain, simulating hernia. 

ing through the tissues, remains in one spot and results in a hematoma. 
Shortly after the accident the hematoma contains fluid blood, but 
this soon clots and remains coagulated for several days. Later, it 
is very slowly absorbed. More rarely it becomes organized and 




Fig. 2. — Hematoma of lip, following a blow. 

persists as a tumor mass more or less permanently. Occasionally 
the surgeon is called upon to treat a hematoma which disappears 
within a few hours. This is apparently due to the slow infiltration 



20 GENERAL INJURIES TO THE SOFT PARTS 

of the blood into the surrounding tissue. In the late stages there 
may be infection which is associated with increasing pain, heat and 
tenderness. 

Treatment.— When seen early the more or less circumscribed, fluctu- 
ating swelling can be observed to increase gradually in size. At 
this time cold applications and firm pressure tend to diminish the 
extent of bleeding. 

After twenty-four hours, when the blood has clotted firmly, a small 
incision may be made and the blood clots expressed from the wound. 

Later, when the mass has become soft and fluid it may sometimes 
be aspirated through a moderate-sized needle. This is often unsuc- 
cessful because small blood clots are apt to clog the needle. In any 
operative plan of treatment the strictest asepsis must be preserved 
as the blood in the hematoma is an excellent culture medium and 
is easily infected. 

If operation is not thought advisable, absorption may be hastened 
by hot applications and massage. 

Suppuration is not uncommon. It may complicate either the 
operative or non-operative cases. When it occurs incision and drain- 
age are indicated. Usually a small incision at a dependent part of 
the swelling meets all requirements. After the hematoma is emptied 
a firm bandage should be applied, the idea being to hold the sides of 
the cavity in apposition so that they may adhere, thus diminishing 
the time required for healing. 

WOUNDS OF THE SOFT PARTS. 

A wound has been defined as a solution in continuity of the soft 
parts. It may be operative or accidental. The following pages are 
limited to the discussion of the accidental variety. 

Wounds ai*e divided into four classes: Incised, puncture, lacerated 
and contused. They may involve the skin or any of the underlying 
tissues, and they may be complicated by the associated injuries or 
by the introduction of foreign material from without. 

The essentials of treatment in all varieties of wounds are: (1) 
The prevention of infection; (2) control of hemorrhage; (3) union 
of the divided tissues. The treatment of accidental incised wounds 
will be given in detail, and the special indications in cases of puncture, 
lacerated and contused wounds will be taken up in their proper order. 

Prevention of Infection.— In accidental wounds infection is the most 
common complication. From the nature of their occurrence and 
because of the unskilled first-aid treatment they often receive, prac- 
tically every accidental wound becomes contaminated by infectious 
material before it is seen by the surgeon. The earlier wounds receive 
skillful medical treatment, the better the results. 

Two plans which aim to prevent the development of suppuration 
are advocated for the treatment of accidental wounds: 



WOUNDS OF THE SOFT PARTS 21 

1. General Lavage.— In this method the wound is opened widely 
and the wound and the surrounding skin are cleansed with soap and 
water, a brush being used both on the skin and tissues to remove 
particles of dirt and other infective material. The excess of soap 
being washed away, the wound is well washed with alcohol and ether 
to remove oil or grease which may have been forced into the cavity, 
and finally, to complete the cleansing process, the wound is well 
irrigated with saline or weak bichloride. 

2. Antiseptic Treatment.— In this plan of treatment gross particles 
are removed from the wound. Lavage of the wound and surround- 
ing skin is avoided on the principle that this treatment tends to 
force infectious material into the wound rather than to remove it. 
A sufficient area of skin is painted with tincture of iodine (one-half 
strength) ; and a swab, dipped in the same solution, is used to paint 
the entire wound, care being taken to reach all the nooks and crevices. 
No lavage of any kind is required. Other antiseptics, such as dichlo- 
ramin-T, carbolic-acid solution, alcohol, etc., have been used in a 
somewhat similar manner. 

The above two plans represent the two opposed forms of treat- 
ment. 1 Many other methods have been recommended, but they are 
either modifications or combinations of the above, or vary only in 
the choice of the antiseptic used or the manner of its application. 
Either of the above methods give a large percentage of wounds that 
heal by primary union. In clinic practice we have used the iodine 
treatment in all cases except those in which a large amount of dirt 
and grime has been ground into the wound. In these cases it has 
seemed wiser to remove as much foreign material as possible by 
complete lavage. 

Control of Hemorrhage.— The methods for the control of hemor- 
rhage will be described elsewhere. In accidental wounds the presence 
of a foreign body, such as a ligature, is to be avoided, and unless 
absolutely necessary, ligatures should not be applied. Capillary 
hemorrhage will cease when the wound is sutured, and hemorrhage 
from a small vein or artery can often be stopped by applying an 
artery clamp and then twisting the clamp off instead of unclamping 
it. In most cases, by the time the wound is seen by the surgeon, 
bleeding has ceased. We have found it advantageous in a few cases 
where hemorrhage persisted to apply directly over the wound dress- 
ing a very tight bandage which is left on for fifteen minutes to half 
an hour and is then replaced by an ordinary bandage. By this time 
capillary oozing will have ceased almost entirely. Occasionally hemo- 
philiac tendencies are first discovered because of persistent hemorrhage 
from an accidental wound. In such cases calcium lactate (grs. xx to 
xl per day) may be given to increase coagulation. Blood transfusion 

1 A third plan, known as "debridement," became very popular with certain surgeons 
during the war. This consists essentially of thoroughly cleansing the wound and remov- 
ing all devitalized and infected tissue. The wound is then closed by primary suture. 



22 GENERAL INJURIES TO THE SOFT PARTS 

and injection of horse serum have both been used successfully in 
such cases. 

Suture of Wounds. —In small superficial wounds if the edges of the 
skin remain in contact no suture is necessary. In more extensive 
wounds where the edges of the skin are separated, or where the motion 
of the body is likely to draw the edges apart or where blood clots or 
other exudates may force them apart, a sufficient number of sutures 
should be applied to the deep and superficial structures to hold them 
in normal apposition. After the wound has been prepared by one 
of the methods outlined above the surgeon prepares his hands and 
instruments in the same manner as for an aseptic operation. It is 
even more important to observe the strictest asepsis in accidental 
wounds than in operative incisions. Because a wound has been 
made with a dirty knife there is no excuse for sewing the wound with 
an infected needle. 

Wounds of the Skin.— Wounds of the skin are best sutured with fine 
silk or horsehair. These cause little scarring and do not readily act 
as avenues of infection. The edges of the skin should be approximated 
as closely as possible, care being taken not to cause puckering of the 
wound edges. 

The needle should be introduced about one-eighth of an inch from 
the edge of the wound from without inward, and carried across the 
wound and introduced exactly opposite from within outward. The 
suture material is then tied and cut. This constitutes a single suture . 
If the wound is closed with several of these sutures it is said to be 
closed with interrupted sutures. In a continuous suture the line of 
sutures is made up of one thread, being tied only at the ends. In 
these sutures the needle should pass directly across the wound, never 
obliquely. 

In wounds about the face and neck where it is desired to avoid 
scarring a subcuticular suture may be used. 1 In this form of suture 
a curved needle is introduced into the cut edge of the skin on alter- 
nating sides of the wound in such a manner that the point of intro- 
duction and exit all occur in the incised edge of the wound. The 
ends of the suture are fastened by means of a small shot clamped 
about the suture. Fine catgut is usually used because it does not 
require removal. In wounds where infection is likely to occur inter- 
rupted sutures are preferable. 

Skin sutures should remain in place from five to seven days, 
depending on the amount of tension. Care should be exercised in 
their removal not to cause gaping of the wound. If skin sutures are 
painted with weak tincture of iodine solution every two or three 
days they will seldom suppurate. Where there is considerable tension 
there is considerably more scar formation than in the case of wounds 
sutured without tension. 

1 If the suture does not penetrate the entire thickness of the skin, an interrupted 
suture may be placed so as to leave no visible scar. A fine needle and fine suture mate- 
rials are required. 



WOUNDS OF THE SOFT PARTS 23 

Sterile adhesive plaster may be used in emergencies and in other 
cases where it is considered inadvisable to introduce sutures. After 
the skin is carefully dried with sterile gauze, narrow strips of adhesive 
plaster are placed transversely across the wound in such a manner 
as to cause coaptation of the cut edges of the skin. In large wounds 
this method is distinctly inferior to sutures. 




Fig. 3. — Complete subcuticular amputation of leg caused by heavy rubber-tired truck. 

Skin shows only slight disturbance. 

Wounds of Muscles.— In deep wounds, muscles are likely to be wholly 
or partially divided. If there is no tension, the cut edges should be 
brought together by means of plain gut sutures; but if their approxi- 
mation is difficult, and if they are likely to be subjected to even a 
moderate amount of tension, fine chromic sutures are advisable. It 
is important to remember that muscle sutures should not be tied 
tightly or they will cut through the tissue. 

Wounds of Tendons.— In wounds about the hands and feet the 
underlying tendons are likely to be severed. Except in wounds 
which are already suppurating, it is wiser to suture the tendon when 
the wound is first seen. It is important not to overlook a cut tendon, 
for its repair at a subsequent operation is usually attended with 
considerable difficulty. 

Tendons should be sutured with fine chromic catgut (No. 1) and 
the sheath sutured with very fine (No. or 00) plain gut. It is 
desirable to bring the cut ends of the tendons into exact approxima- 
tion, and this is best accomplished by means of a mattress stitch 
drawn tightly enough to allow the ends to touch, and one or two 
simple stitches of No. 00 plain gut to hold the cut ends together. 

If one or both ends of the tendon have retracted, the incision should 
be enlarged until they can be secured, the incision being made in the 
long axis of the limb. If the ends of the tendon can be brought 



24 



GENERAL INJURIES TO THE SOFT PARTS 



together they are repaired as described above; but if there is a gap 
between the ends some method is required to bridge over the interval. 

Several methods for tendon repair have been devised. Most of 
them consist of partially dividing the tendon so that it may be 
elongated. 

These methods present technical difficulties and are likely to lead 
to a large percentage of failures. In minor cases the most satis- 
factory procedure is the joining of the ends of the tendon with a 
mattress stitch of medium-weight silk without attempting to bring 
the cut ends together. The stitch acts as a bridge for the formation 
of new tissue and is often followed by complete return of function. 

After the tendon is sutured the wound is closed and the hand put 
up in a splint in a position which relaxes the cut tendon. Gentle 
passive motion should be begun about the third day, and slight active 
movements about the eighth day. After three weeks, when motion 
should be fairly free, the splint may be dispensed with. If stiffness 
follows in spite of passive and active motion it is better to wait for 
several weeks before attempting to break up the adhesions. 




Fig. 4. — Syringomyelia in man, aged fifty-six years, causing the spontaneous loss of a 
number of toes and perforating ulcers of plantar and dorsal surfaces. 

Lesions of Nerves.— Sensory and motor nerves may be divided by 
accidental wounds, especially wounds about the arms and legs. If a 
small sensory nerve is cut it is not necessary to suture it, as the sensory 
functions, after a few T months, are taken on by the adjacent nerves. 
It is, however, a very different affair when a motor or mixed nerve 
is wounded; for unless the nerve regenerates along its original course, 
complete and permanent loss of motor function is the result. 

Consequently the nerve ends should be isolated and sutured 
together with fine catgut or silk. The sutures should be applied, 
as a rule, to the sheath only, usually at least two being necessary. 
As regeneration of the nerve takes place within the sheath of the 



WOUNDS OF THE SOFT PARTS 



25 




Fig. 5. — Numerous recurring bullae on lower extremities following fall on back. No 

other nerve lesion made out. 




Fig. 6. — Paralysis of musculospiral nerve from overlying. (Ashhurst.) 





Fig. 7. — Methods of nerve suturing A, B, sutures passing through sheath and part 
of nerve; C, sutures through sheath reinforced by relaxation suture through entire nerve. 
(Brewer.) 



26 GENERAL INJURIES TO THE SOFT PARTS 

distal portion of the nerve, it is important to secure accurate approxi- 
mation of the cut ends. Ordinarily, nerves joined by side-to-side 
anastomosis will heal together, but regeneration of the nerve fibers 
will not occur. Care should be taken not to twist the nerve on its 
long axis, for in this way the tracts carrying the motor fibers may 
become grafted on a sensory tract and vice versa. For this reason 
it is often better, in the case of medium-sized and small nerves, to 
suture the nerve with a single suture on a very fine needle passed 
directly through the nerve without removing it from its bed. The 
suture should be enveloped if possible with a layer of connective 
tissue or fascia. A complete return of motor function seldom, if 
ever occurs. 

After the wound is closed a splint is so applied as to maintain the 
position in which there will be the least possible tension upon the 
nerve. This position is continued for at least two weeks. Function 
returns in from three to six months or longer, during which period 
a brace should be worn to prevent contraction of the opposing mus- 
cles, and the muscles should be kept in a healthy condition by elec- 
tricity and massage. In mixed nerves sensation usually returns 
before motor function. 

If a nerve has been separated for several months there is probably 
so much degeneration of the fibers that operation will be unsuccessful. 
Suture may be attempted, however, by cutting away the scar tissue 
at the ends of the nerve and bringing it together as described above. 
Occasionally this will be followed by success. 

Suture of the Bloodvessels —In accidental wounds seen in minor 
surgery suture of divided bloodvessels is rarely required. If a large 
vessel is divided, such as the axillary or femoral artery, suture of the 
vessel is indicated. The successful suture of bloodvessels is an opera- 
tion that requires extremely specialized attention to technic and 
considerable experience. 

The operation consists in end-to-end anastomosis with special fine 
silk. The operation is described in detail in works on major surgery. 

Drainage.— It was previously taught that every accidental wound, 
because of the possibility of infection, should be drained from the 
beginning. It is now considered better surgery to suture every 
wound where there is a reasonable probability that suppuration will 
not occur. Even considerable oozing is not an indication for drain- 
age. There can be no doubt that many wounds are infected through 
the drainage opening. The serum discharged into the dressing 
becomes infected, and the infective material extends by direct con- 
tact into the cavity of the wound. Unless infection is practically 
certain, it is better to close the wound without drainage. When 
drainage is used a folded piece of rubber tissue or a small soft rubber 
tube may be used. Strips of gauze are of no value for drainage, for 
they soon become clogged with serum and act as a plug. 

If the wound shows signs of infection it should, of course, be imme- 
diately opened and free drainage instituted. 



WOUNDS OF THE SOFT PARTS 27 

Dressings.— Three different forms of dressings have been advised 
for accidental wounds: 

1. Dry dressings. 

2. Antiseptic dressings. 

3. Continuous wet dressings. 

The advocates of dry dressings base their claims upon the facts 
that wounds heal more rapidly when dry and that the absence of 
moisture is one of the best methods of preventing bacterial growth. 
The wound is dressed with sterile gauze alone or after the wound 
has been dusted with a drying powder, such as bismuth subgallate or 
nosophen. In the ordinary type of accidental wounds, which have 
been well swabbed with iodine, this method gives very satisfactory 
results. 

Antiseptic dressings are usually applied while wet and allowed to 
dry on the wound. Formalin solutions (0.5 per cent), 1 boric acid 
in saturated solution, bichloride of mercury in alcohol (1 to 5000) are 
a few that have been used. In some surgical dispensaries a mixture 
of 1 part of tincture of iodine to 9 parts of glycerin is in common use. 
Dakin's solution and dichloramin-T have recently been extensively 
used by military surgeons. These solutions are supposed to aid in 
the sterilization of the wound and to prevent contamination of the 
dressing which would result in infection. They are usually followed 
by primary union, but are less efficacious for non-infected wounds 
than are simple dry dressings. 

Continuous wet dressings are applied on the theory that, as these 
wounds are possibly infected, it is the best plan to treat them as 
infected wounds from the beginning. This would seem to be a fallacy; 
for it is certain that such treatment causes the wound to heal slowly 
and to be associated almost always with a mild degree of suppura- 
tion. Mercuric chloride in boric-acid solutions (1 to 10,000) , 2 alum- 
inum acetate, Dakin's, or other mild antiseptic solutions, have been 
recommended. Unless infection is present, wet dressings are not 
indicated for wounds which have been sutured. 

Dressings should be changed on the second or third day. If there 
is no evidence of infection and the gauze is adherent the lower layers 
need not be removed. A good working plan is to remove the outer 
layers of the dressing, leaving two or three thicknesses of gauze 
attached to the wound. The daily removal of adherent dressings, 
with the consequent trauma to the tissues and reopening of areas 
for infection, is almost certain to give rise to suppuration in the end. 
About the sixth or seventh day the entire dressing is removed in 
order to permit the removal of the skin sutures. In healing by pri- 
mary union the wound may be left uncovered after the tenth day. 

1 Formalin should not be used on widely open wounds but only on those in which 
there has been satisfactory closure. 

2 It should be remembered that mercury and iodine form a very irritating mercuric 
iodide which may cause severe blistering of the skin. Consequently, mercury solution 
should never be used after preliminary treatment with iodine. 



28 



GENERAL INJURIES TO THE SOFT PARTS 



Suppurating Wounds. — Untreated wounds frequently become 
infected, and suppuration occasionally occurs in wounds where the 
treatment has been most painstaking. When it occurs the wound 
should be opened widely enough to allow thorough drainage. Con- 
tinuous wet dressings promote drainage and tend to limit infection. 
In the treatment of wounds it frequently occurs that there will be 
a small, well-localized infection in one part of the wound, the remainder 
healing by primary union. In these cases only a small opening is 
necessary. Large, suppurating wounds heal by granulation. The 
symptoms of suppuration in a closed wound are increased pain of a 
throbbing character, stiffness and tenderness. These symptoms are 
most likely to occur on the second or third day. They may be accom- 
panied by swelling of the part involved and a rise in body temperature. 
On inspection of the wound, all the signs typical of inflammation 
may be present, viz., heat, redness and tumefaction about the wound; 
but in certain locations as, for example, the palms, these signs may 




Fig. 8. — Skin and thumb torn from arm in auto accident. 

Skin-grafted successfully. 



Deep structures not injured. 



be absent. In some cases the only sign may be the acute tender- 
ness on pressure. Every patient who has a sutured wound should 
be warned to apply for surgical relief in the event of increasing pain 
and tenderness. 

Puncture Wounds. — A puncture wound may be associated with 
tetanus infection. Therefore, a prophylactic injection of tetanus 
antitoxin is advisable. When the wound has been made with a 
clean instrument this precaution is possibly unnecessary; but when 
made with a dirty nail or rake a prophylactic dose of antitoxin should 
always be given. Wounds suspected of tetanus infection should be 
freely opened and swabbed out with iodine through their entire 
extent. Blank-cartridge wounds, in which a pasteboard plug is 
driven beneath the skin, are especially dangerous and should be 
opened widely and all foreign bodies should be removed. After 
swabbing well with tincture of iodine the wound is packed with gauze 
dipped in peroxide of hydrogen, the object being to prevent the 
growth of the tetanus bacillus which is an anaerobe. 



SUBCUTANEOUS INJURIES TO THE SOFT PARTS 29 

Contused Wounds. — These usually contain very little infectious 
material. They may be treated in the same manner as contusions, 
with appropriate attention to the wound of the skin. When there 
has been considerable injury to the underlying tissues extensive 
sloughing may occur. 

Lacerated Wounds. — Wounds caused by machine accidents and by 
instruments tearing through the tissues are known as lacerated wounds. 
They may resemble irregularly-shaped incised wounds, or they may be 
so extensive as to tear the tissues into unrecognizable shreds. It has 
been taught that lacerated wounds should be left wide open, but if 
they are well cleansed (under anesthesia when occasion requires), 
suture of the lacerated areas is often followed by remarkably good 
results. The sutures should be small so as not to interfere with the 
blood supply of the flap, and every portion that can be sutured with- 
out undue tension should be stitched together. Drainage is no more 
necessary than in other wounds, unless infectious material is present. 
Tendons and muscles, if carefully covered, will often regain their 
vitality; whereas, if the wound is left wide open they frequently slough 
away. 

If a large area of skin has been torn away the underlying tissues 
should be allowed to granulate and should then be grafted with skin. 
Even where a large area is exposed, dry dressings seem to give the 
best results. Where the wound is infected the dressings must be 
changed as often as the case demands; but where the wound is clean 
it is unnecessary to remove the adherent gauze from the newly-formed 
granulations, as this process is extremely painful and opens avenues 
of infection. 

Treatment.— In the treatment of the large lacerated wounds seen 
in war surgery the open method was generally adopted. Wounds 
were opened widely and all foreign material carefully removed. Tis- 
sue shreds, particles of bone and other devitalized material were cut 
away and the wound left wide open, generally with the use of Dakin's 
solution or other antiseptic dressings. It must be remembered that 
these wounds were contaminated with the soil and manure of the 
fields and consequently almost certainly infected with virulent organ- 
isms. Infections were frequent and severe. 

In industrial injuries, where there is a possibility of a similar con- 
tamination, radical treatment of this sort is justified. In machine 
injuries, where contamination is of an entirely different character, 
conservative measures should prevail. 



SUBCUTANEOUS INJURIES TO THE SOFT PARTS. 

Without serious damage to the skin, contusions and stretching or 
tearing accidents may cause extensive injury to the underlying soft 
parts. 



30 



GENERAL INJURIES TO THE SOFT PARTS 



Muscle Rupture or Strain. — When a muscle is over-stretched so 
that a few fibers are torn the condition is termed a strain. It should 
be treated by tight bandages, followed by massage. The pain, which 
is acute at first, usually wears off after a week or two. In some 
cases a recurrent strain causes persistent pain. It should be treated 
by adhesive-plaster strapping, so arranged as to prevent those motions 
that stretch the injured muscle to an excessive degree. 

When the tearing of the muscular fibers is more extensive, so that 
the muscle belly is completely torn across, the condition is known 
as rupture. In this lesion (seen frequently in the biceps), when 
movement of the arm is attempted, the proximal portion of the mus- 
cle contracts to a ball-like mass which can be easily recognized beneath 
the skin. Treatment is by incision with suture of the ruptured 
mucle. If untreated, healing is by cicatricial adhesions which leaves 
the muscle weak. 




Fig. 9. — Rupture of short head of biceps, recent. 



Rupture of Tendons. — Sudden muscular contractions may cause 
partial or complete rupture of the tendons. This is most frequently 
seen in the tendons of the quadriceps extensor and plantaris muscles 
of the lower extremities. Depending on the importance and function 
of the muscle, the symptoms may vary from slight disability to com- 
plete loss of function. Pain is usually very acute during the first 
few days. If the muscle is an important one the ends of the tendon 
should be sutured with chromic gut. In some cases, such as rupture 
of the plantaris, the function of the muscle is so slight that no treat- 
ment is necessary except hot applications and rubbing to allay the 
pain and soreness. 

Rupture of the Bloodvessel. — A bloodvessel may be ruptured by 
the tension caused by the hyperextension of a joint. If a large vessel 
is torn there will be extensive ecchymosis, a hematoma, an aneurysm, 
or continuous bleeding into the tissues, in which case the vessel must 



SUBCUTANEOUS INJURIES TO THE SOFT PARTS 31 

be exposed and both ends li gated. If one or more small vessels are 
torn a clot is soon formed in the torn end and the extravasation of 




Fig. 10. — Small traumatic aneurysm of popliteal artery 




Fig. 11. — Winged scapula. Sudden appearance. No etiology other than carrying 

heavy plank on shoulder. 



32 GENERAL INJURIES TO THE SOFT PARTS 

blood is limited to slight ecchymosis. Rupture of the axillary or 
femoral artery may result from reduction of dislocations. 

Rupture of Nerves. — Nerves may be torn completely across by the 
hyperextension of a joint. Thus, cases have been reported in which 
forced flexion of the thigh in the- operation intended to stretch the 
sciatic nerve has caused complete rupture. 

The most common type of this injury is brachial palsy induced 
by the forced separation of the head and shoulder. That is, the 
arm is pulled downward and away from the body, while the head 
is pulled toward the opposite shoulder, causing rupture of the upper 
roots of the brachial plexus. This is the mechanism of Erb's palsy 
which is seen in the new born. The same condition occurs not uncom- 
monly in adult life. This condition should be recognized and referred 
to the hospital for appropriate operation. 

BURNS AND SCALDS. 

Burns are conveniently divided into three classes or degrees. The 
first degree consists merely of erythema of the skin and is most fre- 
quently seen as sunburn. In the second degree the injury extends 
deeper and there is formation of bulla? or blisters. Third-degree burns 
are those in which the injury causes destruction of the tissues with 
the formation of a dark eschar. 

Treatment.— The treatment is general and local. General treatment 
consists of measures to combat shock, and in extensive burns, of 
measures to diminish the symptoms of toxic absorption. In all 
cases where the burns have been severe, morphine should be given 
in full doses for the relief of pain and the prevention of shock. Most 
burns seen in ambulatory practice require little or no general treat- 
ment. Local treatment aims at the relief of pain and the prevention 
of infection. 

In first-degree burns the application of a soothing lotion or a bland 
oil prevents contact with the air and thus relieves pain. Talcum 
powder serves as a protective and in some cases is all thatjs required. 
Bicarbonate of soda solution, lime water or soothing ointments relieve 
the pain. 

In second-degree burns the skin surrounding the burn should be 
well cleansed with soap and water, and the burn and surrounding 
area should be rinsed with large quantities of boiled water and a 
weak solution of bicarbonate of soda. The burn may now be dressed 
with a dry, sterile dressing, or it may be covered with a thick layer 
of boric ointment before the gauze is applied. In cases where pain 
is severe the ointment serves to protect the burn from contact with 
the air with consequent relief of pain. Wet dressings of bicarbonate 
of soda solution have been advised for the relief of pain. The dress- 
ings should be changed every other day. At the second dressing the 
blisters should be punctured with a sterile knife and their contents 



BURNS AND SCALDS 



33 



allowed to escape. The layer of epidermis should never be removed 
unless suppuration is present, in which event the loose epidermis 
should be entirely removed and a wet boric acid dressing applied. 
Picric acid solutions (0.5 to 1 per cent), applied on gauze, act espe- 
cially favorably on burns of this type. Some surgeons prefer to 
treat second-degree burns with a dressing kept wet with a solution 
of bicarbonate of soda. 




Fig. 12. — Extensive burns of back successfully treated by dry air. 



In third-degree burns the surrounding parts are well cleansed and 
the burn washed with saline solution or sterile water. In some cases 
an anesthetic may be necessary for the satisfactory cleansing of the 
injured area. It is advisable to dress third-degree burns dry, for it is 
desirable to secure sloughing by dry, rather than moist, separation 
of the eschar. Later, when the area begins to slough and shows 
healthy granulations, boric ointment may be advantageously used. 
Should infection occur with evident septic absorption a continuous 
3 



34 



GENERAL INJURIES TO THE SOFT PARTS 



wet dressing should be applied. As absorption is rapid from burned 
areas, it is advisable to use only boiled water, or saline, or at the 
most a very weak antiseptic solution. A 2 per cent solution of boric 
acid is a most satisfactory dressing for continuous wet dressings of 
this sort. In the severer types a continuous warm bath (not over 
100° F.) diminishes pain and increases drainage. 

In dispensary patients we have found it very difficult to secure 
proper continuous wet dressings. Patients, after being told to keep 
the bandage "soaking wet," return with the bandage only moist or 
even entirely dry. Consequently, it has been made routine in suit- 
able cases to tell the patient to soak the bandaged part in a basin of 




Fig. 13. — Extensive burns satisfactorily treated by dry air up to twenty-eighth day 
Sudden death from what appeared to be protein poisoning. 



solution at definite intervals; for example, a patient with a suppu- 
rating hand is told to soak the bandaged hand for ten minutes every 
two hours. This serves to keep the dressing wet continuously and 
has been followed by excellent results. 

Many other applications have been used in the treatment of burns. 
Carron oil, a time-tried application, is composed of equal parts of 
linseed oil and lime water. From a scientific standpoint, carron oil 
has little to recommend it and it is being generally discarded; but, 
practically, it acts for the relief of pain in a manner that is decidedly 
grateful to the patient. It may be used when the skin surfaces are 
unbroken during the period when the pain is most acute. It should 
be used freely, several layers of gauze being well soaked with oil 



BURNS AND SCALDS 35 

and applied to the burn, this dressing finally being covered with loose 
cotton and a bandage. 

Picric acid, in a 1 per cent solution, has been favorably recommended 
in the treatment of recent burns. It is said to diminish the acute 
pain, and is known to possess antiseptic properties. Gauze is wet 
with the solution and applied to the burn. Because toxic symptoms 
may result from its absorption, continuous picric acid wet dressings 
are not advisable. 

Certain surgeons advocate the open-air treatment of burns. The 
burned area is simply dusted with a drying powder, such as bismuth 
subgallate or nosophen, and left exposed to the air. This method is 
very painful and rather difficult to carry out without accidental 
injury to the burned area. We have found the use of the open-air 
treatment very valuable in burns after they have reached the granu- 
lating stage. In this method of treatment the granulating area is 
exposed to the open air daily for two or three hours, using direct 
sunlight if possible. This results in a drying-up of the discharge 
and a rapid growth of epithelium. 

Because of the fact that the dressings stick to the burned area and 
when removed lacerate the delicate epidermis and open fresh avenues 
for infection, the application of a non-adhesive dressing of rubber 
tissue has been advised. The tissue is placed over the burned area, 
either in strips or in a single piece, is bandaged in place, and can 
be easily removed without pain or bleeding. As rubber tissue causes 
considerable maceration of the skin, its use should not be persisted 
in for more than a few days. A combination of the open-air treat- 
ment with a rubber-tissue dressing between exposures has given 
especially good results during the stage of granulation. The appli- 
cation of a coating of melted wax over the burned area has recently 
received wide publicity. It was originally introduced in France and 
was known as "the ambrine treatment" from the name of the wax 
used, a secret preparation called "ambrine." Many other wax 
formula? have been advised. The wax offers an air-tight protection 
which does not stick to the burned surface. The dressing must not 
be allowed to remain in place for more than twenty-four hours. Very 
favorable results have been reported. The chief objection to it 
seems to be that it causes retention of all discharges which may lead 
to deep ulceration unless the dressing is frequently changed. The 
burn should be absolutely dry before the wax is applied. 

In burns of the third degree healing by granulation and scar forma- 
tion is likely to be very extensive. Subsequent contraction of these 
scars is apt to result in serious deformities, especially when a burn 
occurs at the flexure of a joint. There are two methods for dimin- 
ishing the tendency to cicatricial contraction: (1) The joint may 
be kept fully extended with an appropriate splint during the process 
of healing; or (2)— and this method is preferable— the granulating 
area left after the eschar has sloughed may be grafted with healthy 



36 



GENERAL INJURIES TO THE SOFT PARTS 



skin b;y the methods of Thiersch or Wolfe. A combination of both of 
these methods is ordinarily used. 

While contractions do not, as a rule, follow second-degree burns, 
the infection which occasionally occurs may cause considerable destruc- 
tion of the skin, so that before the suppuration is controlled there is 
a deep granulating ulcer. Healing, in this event, is followed by deep 
granulation and requires active treatment to prevent contractures. 

Sunburn. — This is a burn of the first degree and should be treated 
accordingly. When extensive areas are burned fever and other 
constitutional symptoms are likely to be present and the patient 
may show marked prostration. In severe cases, as in the case of 
all burns, the patient should be kept in bed. Morphine may be 
required for the relief of pain. 




Fig. 14. — Severe roentgen-ray burn. 



EFFECTS OF INTENSE COLD. 

The local effects of intense cold resemble in some respects those 
of heat. The effect of cold is to cause great local contraction of the 
vessels so that the part becomes livid and finally white. When the 
cold has ceased to act reaction takes place, with congestion and 
erythema. In severe cases there may be an intense reaction with 
exudation which leads to circulatory stasis and gangrene. 

Chilblains. After mild exposure to cold the skin becomes violet-red 
in color, the circulation is sluggish and there is swelling and numbness 
of the part. This condition disappears after a few days, but if the 
exposure is frequently repeated (especially in poorly-nourished indi- 



EFFECTS OF INTENSE COLD 37 

viduals), a condition of constant burning and itching results which 
is known as chilblains. In addition, the skin is likely to become 
cracked and ulcerated. 

Treatment.— After exposure to the cold, the washing of the part 
with cold water to prevent too intense reaction, and bathing with 
alcohol will prevent chilblains. Glycerin, either alone or in com- 
bination with boric acid or tincture of iodine, is of value. Other 
remedies are: ichthyol ointment (10 to 25 per cent), salicylic acid 
ointment (2 to 5 per cent), and balsam of Peru. Applications should 
be made once or twice daily. 

In persistent and troublesome cases tonics may be given and hy- 
gienic measures instituted to build up the general health, and electrical 
stimulation applied in order to give tone to the bloodvessels. In a 
few cases roentgen-ray treatments have been found beneficial. 




Fig. 15. — Frost-bite of second degree; duration, four days. (Ashhurst.) 



Frost-bite. — When any part of the body has been exposed for a long 
period to cold the skin becomes livid and mottled. When reaction 
occurs large bulla?, containing rusty-colored serum, are formed. In 
still more severe cases the skin sloughs or gangrene results. 

Treatment.— For the early treatment it is advised to rub the part 
with cold water or snow. Recent studies seem to indicate that this 
is not so important as was formally believed and that the application 
of warm water is almost as beneficial as snow. In any event, the use 
of cold water should not be too long continued. 

After the circulation returns the part is washed well with soap 
and water and well swabbed with alcohol. A sterile dressing is 
applied which is covered with a protective layer of cotton. When 
bullae appear they should be punctured and an antiseptic dressing 
applied. Sloughs usually separate after a week or ten days. Balsam 



38 



GENERAL INJURIES TO THE SOFT PARTS 



of Peru or other stimulating applications are valuable in the treat- 
ment of the ulcerated surfaces which remain. 

If gangrene occurs it is usually moist in the beginning. If it is 
kept dry with dusting powders and a dry dressing it dries up after 
a few days. It is well to wait for a distinct line of demarcation before 
amputating. In many cases the gangrene involves the skin only, 
so that cases, which appeared to be gangrene of the distal portion of 
the finger, for example, heal with but little deformity after the gan- 
grenous skin has shed. For this reason early amputation is not 
advisable. If, due to infection, gangrene seems to be spreading early 
amputation may be required. 




Fig. 16. — Frost blebs of fingers. Six nails being shed with the blebs forming on fingers. 



Frost-bite pf the Abdominal Wall. — The so-called "ice-cap burn," 
which occurs from prolonged application of an ice-cap, is a superficial 
frost-bite of the skin, and is most often seen on the abdomen during 
the treatment of appendicitis. It occurs when there is no protective 
material between the rubber of the ice-cap and the skin. The treat- 
ment should be prophylactic ; a piece of gauze, handkerchief, or other 
material, should always be placed between the ice-cap and the skin. 
When the skin becomes mottled in appearance, especially if there 
are pale white areas surrounded by erythema, the ice-cap has been 
applied either too cold or too long. Most cases recover in a few 
days if the ice-cap is discontinued; but occasionally the erythema 
persists for several weeks. 

If sloughing occurs the wound should be treated as any granulating 
wound. 

SPECIFIC INFECTIONS. 

Depending on the introduction of the special causative organism, 
certain wound infections are commonly classed as specific infections 
because they present an easily recognizable disease picture and run 
a fairly definite clinical course. Only the salient points in the various 
diseases will be described here. It is, however, necessary for the 



SPECIFIC INFECTIONS 



surgeon to bear these infections in mind, to be constantly on the 
lookout for their earliest indication, and to institute the proper treat- 
ment immediately, should they occur. 

All of these infections gain access to the body from without through 
the medium of an abrasion or wound. Most of them are associated 
with severe general symptoms and in many cases result fatally. For 
details of the course and treatment reference is made to standard 
works on general surgery. 

Erysipelas.— Erysipelas is seen most frequently as a result of wounds 
about the face. It usually occurs on the second or third day, but in 
some cases it may be delayed until considerably later. The disease 
begins with a chill and the wound shows an area of surrounding 
dusky redness with a well-marked, irregular margin raised slightly 
above the level of the normal skin. When 
the infection occurs the patient should be 
isolated and measures at once instituted 
to combat the disease. 

Tetanus.- — Tetanus is aninf ectious disease 
due to the bacillus of tetanus w r hich gains 
entrance by a broken surface. The bacillus 
is frequently found in horse manure and is 
consequently fairly frequent in wounds in- 
curred about stables, in the streets or in 
fertilized fields. As the bacillus will not 
grow in the presence of oxygen, the disease 
is most commonly seen after puncture 
wounds, although it may occur after large 
lacerated wounds or even incised wounds. 1 
The incubation period is from four days 
to three weeks. Occasionally a case occurs 
several months after the wound has healed. 

The onset of the disease is marked by muscular spasm, often begin- 
ning in the face (lockjaw). This is soon followed by general muscular 
spasms, both tonic and clonic, and severe constitutional symptoms. 
The disease is serious, but if proper treatment is instituted as soon 
as the symptoms appear a large number of cases recover. 

Treatment. —The prophylactic treatment of tetanus is of great 
importance to the surgeon. Tetanus prophylaxis should be given in 
every case where the wound is known to be infected with dirt or grime 
thought to contain horse excreta. In gunshot wounds, blank-car- 
tridge wounds and other puncture wounds foreign material is fre- 
quently present and these wounds are usually considered as infected. 
In the recent war tetanus followed many cases of trench-foot, the 
organism apparently gaining entrance to the body through a small 
scratch or abrasion. 

1 Recent studies would seem to indicate that tetanus is more common in wounds 
where there has been gangrene of the cutaneous flap. 




Fig. 17. — Erysipelas, but- 
terfly type ; duration, one day. 



40 



GENERAL INJURIES TO THE SOFT PARTS 



The prophylactic treatment of tetanus is carried out as follows: 
The wound is widely opened under either local or general anesthesia 
and all foreign material is carefully removed. Blackened and lifeless 
tissues are excised, and the wound is swabbed thoroughly with tincture 
of iodine. It is then packed with sterile gauze, so that it may heal 
from the bottom, and washed out daily with an antiseptic solution of 
peroxide of hydrogen. As soon as possible after the injury a pro- 
phylactic dose of tetanus antitoxin (1000 units) is injected into the 
loose tissues of the back. 

In war surgery, where cases of tetanus were very likely to occur, 
it was the practice to give a prophylactic dose of antitoxin to every 
wounded soldier.* While it is not considered necessary to go quite 

this far in civil practice, the surgeon 
should appreciate his responsibilities 
and make use of antitoxin in every 
suspicious case. 

After the disease has developed 
general measures for the care of 
tetanus should be instituted. Anti- 
toxin should be used in full doses, 
but its value is much less than when 
given at the time of the injury. 

Anthrax. — Anthrax is due to infec- 
tion with the B. anthracis which is 
common in cattle, sheep and other 
domestic animals of certain com- 
munities. The dried wool, hair and 
hides of these animals when smeared 
with blood will retain the infection 
for a long time. Hence, we expect 
to find the disease in wool-sorters, 
tanners, etc. 1 

At the point of inoculation there 
is a small vesicle which soon turns 
to a black ulcer, often surrounded with small vesicles (malignant 
pustules). At the beginning there are few constitutional symptoms; 
but later they may become very severe. There is usually about the 
wound an area of edema out of all proportion to the apparent size of 
the lesion. 

Treatment.— In every suspected case the discharge should be exam- 
ined for the anthrax bacillus. When a malignant pustule develops it 
should be excised and the area should be swabbed with pure carbolic 
acid. Constitutional treatment should be begun at once. Recently 
a serum has been prepared by the U. S. Department of Agriculture 

1 Ordinary cleansing will not remove the infection from the infected material. 
Recently several cases have been reported where a new shaving brush proved to be the 
carrier. 




Fig. 18. — Angioneurotic edema of 
face, recurring for three months, follow- 
ing injection of tetanus antitoxin. 



SPECIFIC INFECTIONS 



41 



known as Eichhorn's serum. This serum has protective action 
against anthrax infection, and should always be used both locally 
and intravenously. Favorable results have been reported, but it is 
too early to form a final judgment as to its merits. 

Hydrophobia. — Hydrophobia results from the introduction of the 
virus of rabies through a bite, wound or other injury to the skin. 
It is most often transmitted by dogs. 




Fig. 19. — Actinomycosis of lower dorsal spine, showing granules. 

If a wound is suspected of being infected with this virus it should 
be widely opened and cauterized either with pure carbolic acid or 
the actual cautery. The animal should not be killed but kept under 
observation until it is determined with certainty whether it is suffer- 
ing from rabies or not. If the animal is found to have had rabies 
the Pasteur preventive treatment should be begun at once. 

Other infections, such as diphtheria, actinomycosis, glanders and 
tuberculosis, may infect a local wound. These conditions are very 
rare as wound complications and when they occur the severity of the 
complicating condition overshadows the primary wound. The treat- 
ment varies with the causative condition. 



CHAPTER II. 
FRACTURES IN GENERAL. 

Before taking up the diagnosis and treatment of specific fractures 
it is necessary to consider in detail the symptoms and the physical 
signs of fractures in general. Specific fractures will be discussed in 
the chapters devoted to regional classification. 

Symptoms.— The symptoms of fracture may be classified for con- 
venience as follows: 

Subjective symptoms: 

1. Pain. 

2. Loss of function. 
Objective symptoms: 

3. Swelling. 

4. Ecchymosis. 

5. Deformity. 

6. Tenderness. 

7. Preternatural mobility. 

8. Crepitus. 

9. Bony irregularity. 

10. Roentgen-ray findings. 

The above symptoms are the classical symptoms of fracture, but 
they are seldom all present in any given case. Two symptoms, 
crepitus and preternatural mobility, are pathognomonic of fracture. 
If they can be unmistakably demonstrated the case is certainly a 
fracture. If the roentgen-ray examination shows a distinct fracture 
the diagnosis is certain. A negative roentgen ray is of much less 
value. However, careful examination will in most cases permit the 
diagnosis of fracture, even in the absence of any of the so-called 
pathognomonic signs. Indeed, in the ordinary examination it is 
rarely, if ever, necessary to elicit either crepitus or false point of 
motion in order to confirm the diagnosis made by means of other 
objective symptoms. 

1. Pain.— While pain is a subjective symptom and consequently 
liable to exaggeration or suppression in different subjects, its import- 
ance should not be underestimated. Except in certain cases due to 
nerve or cerebral change, it is practically a constant accompaniment 
in every fracture. There is a history of severe pain at the time of 
injury as well as of pain occurring later with the increase of the swell- 
ing. 1 Spontaneous pain when the limb is at rest is usually slight, 

1 In every lesion accompanied by sudden swelling, the pain is largely due to pressure 
on the nerve-endings in the tissues. 



FRACTURES IN GENERAL 43 

but there is severe pain on active motion or passive movement of 
the part. 

2. Loss of Function. — Loss of function of the injured limb is a 
common result of fracture. However, except in the most severe 
fractures, function is rarely completely lost, and in many cases is 
only slightly interfered with. This symptom results either from 
mechanical causes, such as the loss of the ordinary lever action of 
the bone, or from the inhibitory action of pain or fear of pain. As 
the pain after the first shock is often slight, and as many other con- 
ditions may upon occasion cause loss of function, the presence of 
this symptom is suggestive, but not indicative, of fracture. Its 
absence, in the same manner and for the same reasons, does not 
exclude injury to the bone. Individuals are constantly presenting 
themselves who have been able to perform their routine labor for 
some time after the occurrence of the injury without serious loss of 
function. Thus a chauffeur with a fractured radius drove his car 
for three days, and a woman was able to attend to all her housework 
during a period of three weeks while suffering from a fractured patella 
in which there had been only slight separation. Fractures of the 
metacarpal bones, which have entirely healed without treatment and 
in which there has been only slight interference with function during 
the entire period of healing are frequently seen in any dispensary. 

3. Sivelling.— Swelling in recent fractures is due to effusion into 
the soft parts. It is of diagnostic importance only in combination 
with the history of the injury. It is apparent that if, for example, 
after a fall upon the hand we find a swelling at some distant region, 
for instance, about the wrist-joint, we may safely presume an injury 
to some tissue in that region, possibly the radius or the ulna. If the 
swelling occurs at the point of trauma it is of less diagnostic import- 
ance because of the direct injury to the soft parts. In like manner 
its importance is lessened in the region of the joints, for here we have 
to differentiate fracture from sprain and dislocation. 

The persistence of a hard deep swelling, which remains firmly 
attached to the bone after the edema of the soft parts has disappeared, 
is indicative of callus and is most noticeable about three weeks after 
the injury. 

4. Ecchymosis.— Ecchymosis has some value in the diagnosis of 
fracture. When it occurs early it is the result of injury to the soft 
parts. When it occurs late, after twenty-four hours, it is the result 
of injury to the bloodvessels of the deep structures and may first 
appear at some distance from the seat of injury. 

In the absence of early ecchymosis this late development of the 
symptom is suggestive of fracture. 

5. Deformity.— The term deformity should be used in its broadest 
sense to include not only changes evident to inspection and palpation 
but also that deformity which can be distinguished only by mensu- 
ration. Deformity may be angular or due to the overlapping or 



44 FRACTURES IN GENERAL 

impaction of the bone. It is likely to be obscured by the swelling 
and is consequently most apparent immediately after the fracture and 
after several weeks when the swelling has subsided. Angulation, 
when present especially in the shaft of the bone, is a positive sign of 
fracture. In the vicinity of a joint, especially where there is much 
swelling, this symptom has considerably less significance. The 
deformity due to overlapping and impaction is less apparent and can 
be determined only in superficial bones or by careful measurements. 
Most of the text-books mention mensuration as an important aid in 
the diagnosis of fractures, while it is common experience that the 
results are unsatisfactory, or at best merely confirmatory. 

There are two difficulties which prevent the general employment 
of mensuration: Its inaccuracy and the normal variation in the two 
sides of the body. The human skeleton has a movable covering of 
skin which prevents the use of well-defined points between which 
measurements may be made. The points usually selected are the 
bony prominences which lie close beneath the skin and which con- 
sequently are easily palpable. They present, however, rounded 
extremities, as a consequence of which absolute accuracy in the 
measurement of distance is impossible. Moreover, it is asserted 
that there is occasionally a normal asymmetry, not due to traumatism 
or disease, which is sometimes very noticeable, occasionally being as 
much as an inch and a half in the lower limbs. In the region of the 
fracture the swelling of the soft parts is sufficient to make accurate 
measurements practically impossible. Careful and minute exami- 
nation of the anatomical landmarks by inspection and palpation, 
including comparison with the uninjured side, is the surgeon's best 
guide. 

In the examination for deformity it is important to ascertain from 
the history whether there has been any previous injury of the affected 
part, as an old deformity has occasionally been mistaken for a recent 
fracture. 

In general, if the deformity is marked and characteristic it is indica- 
tive of fracture. However, in these cases the other symptoms are 
usually present and the diagnosis is easily made. In impacted fract- 
ures and fractures near joints the presence or absence of deformity 
is of considerably less value. 

6. Tenderness.— Tenderness is closel t y allied to spontaneous pain 
and is the most important single sign in all classes of fractures. It 
is present in linear and impacted fractures where most of the other 
symptoms are slight or absent, and it deserves most careful study 
and consideration. In some cases it is sufficient in itself for diagnosis, 
even without any other objective signs. We have made the diag- 
nosis of fracture upon the history of a particular type of trauma com- 
bined with characteristic localized tenderness, but with negative 
roentgen-ray findings. Our diagnosis was confirmed later by callus 
formation about the point of fracture. 



FRACTURES IN GENERAL 45 

Tenderness may be elicited in two ways: (1) By local pressure 
upon the point of fracture; (2) by indirect pressure upon the ends 
of the broken bones. 

Indirect tenderness is of less value than direct because it is often 
absent or obtained with difficulty. When present and referred 
definitely to a well-defined area the indications are fairly definite. 
For instance, in fracture of the lower end of the fibula pressure upon 
the upper end of the bone may cause pain referred to the external 
malleolus if there is some movement of the fractured ends of the 
bone and if the injury is recent. When clearly present it is of value; 
when absent it is of little value as a reason for excluding fracture. 

Localized tenderness, on the other hand, is of extreme importance. 
Its absence is a positive means of excluding fracture. Its presence 
always points to bone injury and it may be demonstrated for a period 
of three weeks or longer after the fracture has occurred. It is partially 
obscured by effusion into the soft parts which causes tenderness over 
a large area for the first few days, and it may be stimulated by localized 
trauma to the bone. Local tenderness may best be elicited by the 
examining finger, or by a small object, such as the rubber-tipped end 
of an ordinary lead pencil. The tenderness of fracture, called by 
Skillern ''wincing tenderness," is of a peculiar type, and is especially 
characteristic of bone injury. In examining an area of suspected 
fracture the bone is palpated with the end of the finger along the 
most superficial surface, and firm, even pressure is made in successive 
areas approaching the injured portion of the bone. While a con- 
siderable area is painful on pressure, when the line of fracture is 
reached the patient is noticed to wince perceptibly. If this is in an 
area of the bone where there has been no direct trauma, and if, in 
addition, there is some swelling of the part, the diagnosis of fracture 
may be made practically without qualification. With care the com- 
plete line of fracture can be mapped out, and the presence of com- 
plicating fractures of other bones clearly excluded. This wincing 
tenderness is most clearly shown immediately after the accident, or 
after a few days, when the edema of the soft parts has decreased. 
The localized tenderness persists for several weeks and is usually the 
last sign of fracture to diappear. In old fractures the pressure should 
be made considerably harder, but it is possible to outline accurately 
a fracture of a superficial bone three weeks or even longer after the 
accident has occurred. 

In sprain and dislocation wincing tenderness is present, but in 
these conditions it is located over the tear in the ligament rather 
than at some point on the bone. 

7. False Point of Motion.— False point of motion is mobility appear- 
ing after the injury at a point in a bone where it did not previously 
exist. Its presence is positive proof of fracture, but its absence does 
not indicate intact bone because in the majority of fractures abnormal 
mobility cannot be demonstrated, It is usually absent in incomplete 



46 FRACTURES IN GENERAL 

fractures, in impacted fractures and fractures in the neighborhood of 
joints. The manipulation required for the detection of abnormal 
motion varies according to the portion of bone involved. It is most 
easily obtained in the shafts of long bones. The mobility may con- 
sist of angulation at the point of fracture, movement of the fractured 
surfaces upon each other in any direction, modification in the amount 
of overlapping or rotation of one fragment upon the other. 

In some cases false point of motion is easily detected; in other 
cases it is absent or only evident through the exertion of considerable 
force in the examination. Before the advent of the roentgen ray it 
was the custom to anesthetize the patient in order to obtain this 
symptom, and in the manipulation displacements were often caused 
which otherwise would not have occurred. Even in the absence of 
the roentgen ray, forcible manipulation for the demonstration of abnormal 
mobility is an unnecessary, unjustifiable, and in many cases a dangerous 
procedure. 

8. Crepitus.— Crepitus, like abnormal mobility, is rapidly falling 
into disuse. When obtained easily without forcible manipulation it 
is practically pathognomonic of fracture. The same caution, which 
has just been sounded regarding false point of motion, applies to 
crepitus, and the same dangers exist. 

This symptom is described as the peculiar grating sensation which 
is transmitted to the examining hand when the roughened ends of 
the bone are moved one upon the other. In some cases it is loud 
enough to be heard by bystanders some feet from the patient. As 
its presence presupposes abnormal mobility, it is absent in impacted 
and greenstick fractures. The interposition of blood clots or tissue 
prevents crepitus, even in cases where there is distinct abnormal 
motion. Bony crepitus may be simulated by the crepitus due to 
subcutaneous hemorrhage or subcutaneous emphysema, or by the 
crepitus which accompanies acute and chronic inflammatory con- 
ditions of the synovial membranes. However, to the experienced 
surgeon, bony crepitus has a characteristic quality which is unmistak- 
able. 

9. Bony Irregularity.— Bony irregularity is, strictly speaking, 
included under deformity. It is, however, usually determined by 
palpation and may be determined either at the seat of the fracture 
or as a change in the relation of the bony prominences. In Colles' 
fracture the irregularity may be felt directly at the lower end of the 
radius and indirectly in the change of the relation of the styloid 
process of the radius and ulna. After the first few hours bony irregu- 
larity is obscured by the swelling of the soft parts so that it is best 
obtained immediately after the fracture or after the swelling has 
subsided. It may be absent in some cases of fracture and it is diffi- 
cult to demonstrate in others, but when undeniably present it is a 
valuable sign and should always be searched for. 



FRACTURES IN GENERAL 



47 



10. Roentgen-ray Examination.— Roentgen-ray examination has 
added a great deal to our knowledge of fractures. In particular it 
has enabled us to demonstrate that localized, wincing tenderness is 
the most reliable symptom of fracture and that it is in itself sufficient 
to warrant a positive diagnosis. It is to be emphasized that the 
roentgen ray is a confirmatory evidence only, and that errors of 
interpretation are by no means rare. Frequently, darkened portions 
of the roentgenograph are mistaken for fractures, where from the 
clinical evidence it is apparent that no fracture exists; and still more 




Fig. 20.— Fracture of transverse process of third and fourth lumbar vertebrae. Symp- 
toms of lumbago. 

frequently the plate is found negative, when the course and symptoms 
prove definitely that fracture exists. In the examination the expo- 
sures must always be made in at least two diameters of the limb. 
It is not uncommon to have two or more plates in which no fracture 
is shown, and finally to get a distinctly positive result in the third 
or fourth roentgenograph. A case recently presented itself in which 
the clinical diagnosis of fracture was made in spite of several negative 
roentgen rays. Because of the typical symptoms, the treatment for 
fracture was carried out and the diagnosis was confirmed by the 



48 



FRACTURES IN GENERAL 



formation of callus which showed plainly in a plate taken three weeks 
after the accident. 

In children, because of the lesser degree of ossification, the inter- 
pretation is even more difficult than in adults ; while in the aged, owing 
to degenerative changes in the bones, irregularities often exist which 
to the inexperienced may have the appearance of incomplete fractures. 

In fractures with much displacement it is important to have a 
roentgen-ray examination after reduction in order to determine if 
the fragment is satisfactorily reduced. 




Fig. 21. — Fracture of second lumbar vertebra following fall in the sitting position; no 
cord symptoms. Patient able to walk. 



In the treatment of fractures the following rules regarding roentgen- 
ray examination are of sufficient importance to bear repetition: 

1 . Every case of suspected fracture should be subjected to roentgen- 
ray examination. This gives the physician a permanent record which 
is important from a legal viewpoint. 

2. Roentgenographs should always be taken in at least two diameters 
of the injured part. 

3. The results obtained should be considered only as presumptive 



SPECIAL VARIETIES OF FRACTURES 



49 



evidence for or against fracture, except in plates showing displace- 
ment. 1 

4. The roentgen ray should be used frequently as a means of deter- 
mining the accuracy of reduction in all fractures with marked dis- 
placement. 

5. Always make the clinical diagnosis before examining the roent- 
genograph. If they do not agree depend more upon the clinical 
results, unless further examination permits the correlation of the two. 

Additional methods of diagnosis have been advanced from time to 
time, such as auscultatory percussion, examination under anesthesia, 
etc. They are rarely indicated or desirable, and the results obtained 
are seldom significant except in those cases in which the diagnosis 
is made certain by other means. 

SPECIAL VARIETIES OF FRACTURES. 

There are several varieties of fractures which require special men- 
tion. In the main they are to be treated as simple fractures and will 
be discussed briefly, only the features which require special considera- 
tion being indicated. 




Fig. 22. — Spontaneous fracture of lower jaw secondary to inoperable sarcoma. 



Separation of the Epiphyses.— This is really a fracture-dislocation 
at the junction of the epiphysis with the diaphysis. This is most 
frequently seen in children from the fifth to the fifteenth year, but 
it may occur at any time from birth to adult life. 2 The reduction 
must be accurate, otherwise growth will be interfered with. With 
complete reduction healing and restoration of function are the rule. 
Owing to its influence on the growth and development of the bone, in 

1 It should be remembered that in the thicker portions of the body, such as the back 
and thigh, a fairly large sliver or fragment of bone may be broken off without showing 
in the ordinary roentgenograph. 

2 We have a record of a birth injury showing separation of the lower epiphysis of the 
femur. 

4 



50 



FRACTURES IN GENERAL 



no case should an epiphyseal separation be allowed to remain in an 
abnormal position. In neglected cases open operation is often advis- 
able. 

Greenstick Fracture. — Greenstick fracture is another fracture which 
occurs during childhood. The susceptibility to this type of fracture 

diminishes with age, but it may oc- 
casionally be seen as late as early 
adult life. It is most common in very 
young children. In some cases it may 
be necessary to complete the fracture 
before reduction is possible. Usually, 
however, if the deformity is slightly 
overcorrected it does not tend to recur. 
Spontaneous Fracture.— Whenever, in 
a case of fracture, the injury to the 
bone is out of all proportion to the de- 
gree of trauma given in the history, the 
suspicion of spontaneous, or pathologic, 
fracture should arise. 

Certain general conditions, such as 
disease of the nerve centers, diabetes, 
rachitis, osteomyelitis, senility, syphilis 
and rheumatism, may cause an extreme 
brittleness of the bones, in consequence 
of which spontaneous fractures are not 
uncommon. 

In ambulatory cases local disease of 
the bone is more commonly associated 
with spontaneous fracture. New growths, 
especially sarcomata and cystic degen- 
eration, are seen fairly often, and 
osteomyelitis less frequently, as pre- 
disposing causes. 

The treatment of spontaneous, or 
pathologic, fractures is to a large degree 
dependent upon the cause, although 
healing is usually rapid and complete 
under the ordinary methods of treat- 
ment. However, if the underlying condition is not removed recur- 
rence is practically always assured after a longer or shorter interval. 




Fig. 23. — Paget's disease. Note 
enlargement of cranium and de- 
formity of extremities with recur- 
rent fractures. 



THE TREATMENT OF FRACTURES. 

In general, the treatment of fractures may be divided into four 
stages. 

1. Temporary treatment. 

2. Reduction. 

3. Retention. 

4. Restoration of function. 



THE TREATMENT OF FRACTURES 51 

Temporary Treatment.— In a few cases the conditions are such that 
when the fracture is first seen reduction may be performed imme- 
diately and a permanent splint applied. Under ordinary conditions 
if the fracture is seen within the first few hours it is well to make a 
careful examination before the bony landmarks are obliterated by 
the swelling of the soft parts. If the conditions seem favorable an 
attempt at reduction may be made, and if successful a permanent 
dressing applied. However, in most cases temporary measures are 
necessary. 

In general, the temporary treatment consists of splinting the 
injured limb in such a manner that the patient may be moved to a 
more convenient spot without further injury to the bone or soft 
parts before reduction and permanent splinting are attempted. Splints 
may be made in emergencies from cardboard, boards, sticks, umbrellas, 
canes, etc. 

Reduction. —Reduction consists of the replacement of the bone 
in a position as nearly normal as possible. In fractures without dis- 
placement and in some impacted fractures no reduction is necessary. 
In some cases reduction is practically impossible, owing to the small 
size and inaccessibility of the fragments, the interposition of soft 
parts, or malunion. The best time for reduction is undoubtedly as 
soon after the accident as is compatible with the convenience of the 
patient and the facilities of the surgeon. While many fractures 
can be satisfactorily reduced several days after the accident, there 
is no doubt that better results are obtained from early reduction. 
The displacement of the fragments make for increased hemorrhage 
and swelling of the surrounding tissues, and this infiltration of the 
soft parts, besides adding to the pain and discomfort of the patient, 
is a distinct obstacle in reduction. 

Anesthesia is usually necessary for satisfactory reduction. Unless 
the fragments can be replaced accurately without serious pain, some 
form of general anesthesia is required. Nitrous oxide is the anesthetic 
of choice in these cases, although deeper narcosis with ether or chloro- 
form is sometimes necessary. Impacted fragments should not be 
broken up if there is no lateral displacement. In the aged and where 
nutrition is poor it is often better not to interfere with impaction 
even if there is considerable displacement, provided function is not 
seriously interfered with. Reduction is usually secured by manipu- 
lation and traction. The methods vary with the different fractures, 
and will be discussed in detail under their separate headings. 

Retention of Fractures.— The Use of Splints. —After the reduction 
of a fracture a form of apparatus is necessary to prevent the recur- 
rence of deformities. This is called a splint and may be made of 
various materials which have sufficient firmness to support the frac- 
tured limb and to prevent the displacement of the fractured bones. 
For ordinary use a splint should be strong enough not only to hold 
the parts in alignment, but to protect them against the accidental 



52 FRACTURES IN GENERAL 

trauma of daily life which may be incurred by involuntary move- 
ments during sleep or in slipping, etc. The splint takes on to a 
certain extent the function of the injured bone by supporting the 
limb during the process of repair. Many fractures which show no 
tendency to displacement could be allowed to heal without the use 
of splints were it not for the danger of accidental injury which would 
cause an increased amount of pain and recurrence of the deformity. 

The Wooden Splint— This is the simplest form of splint. It should 
be made of soft wood about one-eighth of an inch in thickness. The 
ordinary basswood splints are usually too thin, and when used for 
the arm or leg two or three should be fastened together. The wood 
should be soft and light, but firm enough not to bend under moderately 
strong pressure. It should be trimmed to the desired length and 
breadth, and the side which is to be next to the injured limb should 
be carefully padded. Cotton is a very satisfactory padding. It is 
placed along the splint in a smooth layer and a circular gauze bandage 
used to hold it in place. This gauze bandage makes a clean white 
covering which can be removed when it is soiled. It serves an 
added purpose by preventing the splint from slipping after it is 
bandaged to the limb. 

In most recent fractures, in which considerable swelling is antici- 
pated, wooden splints are preferable to any other type. In such 
cases after reduction, the arm or leg being held by an assistant, two 
splints are applied and held in place by a circular bandage. If the 
splints are a little wider than the injured part there is absolutely no 
danger of constriction because of the lateral space which will allow 
for swelling. The advantages of wooden splints are their cheapness, 
availability, ease of application and the absence of danger from con- 
striction. They are often unsatisfactory because they become loose 
and slip about; they do not secure perfect apposition of the injured 
parts; they are clumsy and constantly in the patient's way; and 
they are especially likely to cause pressure sores upon the bony promi- 
nences. They are preferable only in cases of recent fracture, and in 
some cases where there is little or no liability to displacement. 

Plaster-of- Paris Dressings for Fractures.— Plaster of Paris, on ac- 
count of the ease and accuracy of its application to the irregularities 
of the body, combined with its lightness and rigidity, is the material 
best adapted for supporting bandages and splints in the treatment 
of ambulatory fractures. 

For their preparation the following materials are necessary: (1) 
Plaster of Paris; (2) plaster-of -Paris roller bandages; (3) flannel roller 
bandages; (4) sheet wadding made into rolls; (5) heavy bandage 
scissors; (6) heavy knife for cutting plaster; (7) gauze bandages. 

For ordinary practice the prepared plaster bandages, which can 
be obtained from surgical supply houses, are most satisfactory. They 
are shipped usually in air-tight tins containing an excess of loose 
plaster which is available for use when needed. If these are not 



THE TREATMENT OF FRACTURES 53 

obtainable bandages may be easily prepared according to the follow- 
ing directions: Good quality plaster should be secured, the so-called 
dental plaster being the best. Ordinary commercial crinoline, prefer- 
ably sized with starch, is used as a foundation and is cut into strips 
from three to six yards long, and usually two, three or four inches 
wide. Bandages narrower or wider than this are very rarely required. 
The bandage is placed on a smooth surface and sufficient plaster is 
rubbed on a part of it to fill the meshes of the cloth. This end of 
the bandage is then lightly rolled and the process is repeated with the 
next adjoining portion, which in turn is rolled, and this is continued 
until the meshes of the entire length of the roll are filled with plaster. 
The rolled bandage is then wrapped in paper, the ends of the paper 
being folded in so as to enclose the bandage. The package should be 
held together by a string or rubber band and stored in a dry place. 
If protected from moisture these bandages will keep indefinitely. 
Bandages which have become moist should be well dried in a hot 
oven; but if the moisture has caused the plaster actually to set they 
had better be discarded. 

For the immobilization of fractured bones after reduction plaster 
of Paris is probably the most satisfactory form of dressing. In 
general, there are certain rules which should be followed out in all 
plaster work, and borne in mind in every case. 

1. Observe carefully the dangers of constriction. Nearly all plaster 
dressings are applied closely to the injured part and care must be 
taken, especially in recent fractures, to allow for subsequent swelling 
of the part. This can usually be accomplished by the use of sufficient 
padding or by frequent and systematic attention to the condition of 
the part, guarding against the danger of a constricting bandage. In 
general, it is well to pad recent fractures liberally, and to examine 
the bandaged limb daily. In addition, it is well to call the attention 
of the patient and his attendants to the danger of constriction and to 
give instructions to cut or loosen the bandage when in doubt. A 
loosened splint for twenty-four hours can do little harm, while con- 
striction of the limb for the same period may cause irreparable damage. 

As recent fractures and traumatic injuries are liable to continue 
to swell for some time after the application of a plaster dressing, it 
has been our custom to split from end to end all encircling plaster 
bandages, plaster spicas and so-called plaster casts with their under- 
lying dressings. (See Colles' and Pott's fracture.) In fifteen years 
of clinical practice we have found that this splitting allows closer 
application of the plaster dressing and the consequent firmer support 
of the injured part, at the same time eliminating any possibility of 
ischemia due to constriction. 

2. Avoid pressure upon bony prominences. Pain, especially when 
at a point distant from the fracture, may indicate pressure upon some 
bony prominence. This should be relieved within a few hours or a 
troublesome pressure sore may result. 



54 FRACTURES IN GENERAL 

3. A roentgenograph after reduction is almost always desirable. 

4. Fixation of the joints above and below the point of fracture can 
be secured by including them in the splint. 

5. Early passive motion and massage will prevent stiffness of the 
joint and atrophy of the muscles. 

The Preparation of Plaster Splints. —After deciding upon the length 
of the molded splint, or splints, required for the individual fracture, 
a piece of flannel bandage, long enough to overlap the ends by about 
two inches, and wide enough to overlap the sides by an inch or more, 
is cut out and placed, with the nap side downward, upon a table or 
any other flat surface. The splint should be wide enough to encircle 
about one-third of the limb, and long enough to immobilize the joints 
above and below T the fracture. The plaster bandage should be placed 
upon its side in a basin of warm water sufficiently deep to cover the 
bandage entirely. After the bubbles have ceased to rise (usually in 
three or four minutes) the bandage is removed and squeezed partially 
dry to remove the excess of water. The method of squeezing is 
important, the bandage being grasped with the entire hand, and firm 
pressure applied once only. Under no condition should the bandage 
be u milked" or dipped into the water again, because this removes too 
much of the plaster from the meshes. The loose end of the bandage is 
then placed upon the strip of flannel near the end, and held by the 
left hand, while the bandage is unrolled to the other end of the strip. 
The bandage is then taken in the left hand and the second layer 
placed directly over the first. The two are rubbed together by one 
or more strokes with the right hand from left to right. The bandage 
is then changed to the right hand and the process of stroking is carried 
on with the left hand, from right to left. This is repeated until the 
entire bandage is used up, or the splint has the required thickness. 
For most purposes, about a dozen thicknesses are sufficient. The 
overlapping flannel is folded inward toward the center, serving to 
finish off the edges of the splint. 

When the splint is finished it may be applied either directly to the 
skin or over a preliminary padding of cotton. After its application 
to the limb it is held firmly in place while an assistant applies a gauze 
bandage to the injured extremity in such manner as to mold the 
splint firmly to the irregularities of the part. The extremity should 
be held by the surgeon for five or ten minutes in the position most 
favorable for healing, and then the assistant or the patient himself 
should be instructed to hold the part in the same position until the 
splint has hardened. This should require at least thirty minutes, 
although plaster sometimes hardens more rapidly. If conditions will 
allow it is well to wait until the splint is perfectly dry before putting 
any strain upon it. Some surgeons prefer to remove the splint after 
the plaster has set and allow it to dry in the open air. The prepara- 
tion and application of this type of splint should proceed rapidly, 
otherwise the plaster may begin to set before the molding of the 
splint is completed. 



THE TREATMENT OF FRACTURES 55 

When more than one bandage is to be used to form a splint the 
second bandage is placed in water when the first is taken out. When 
the first is completely applied the second will be ready to be taken 
from the water. In some cases basswood strips or bands of metal 
may be incorporated in the splint in order to give additional support. 

Plaster splints have the advantage of lightness combined with 
firmness, and they are easily removed for purposes of massage and 
passive motion. When, on account of unusual stress, they are cracked 
or broken, they should be reinforced with additional plaster or, what 
is better, a new splint may be made. If they are allowed to become 
wet they soon grow soft and pliable and must be replaced by new ones. 
In rare cases they do not set at all, or, at best, harden irregularly. 
This is due to the use of a poor quality of plaster of Paris. 

Circular Plaster Splints.— The technic of the application of plaster 
splints, sometimes called plaster casts, is somewhat similar to that 
of the plaster bandage. After the limb is carefully washed and dried 
it is covered with a smooth layer of cotton, or other material suitable 
for padding, thick enough to serve as protection for the bony promi- 
nences and to allow for a certain amount of swelling. It is often 
found convenient and expedient to cover the arm or leg with smooth- 
fitting underwear and over this to wind loosely cotton wadding which 
has been cut and rolled in bandage form. This is made especially 
thick where there is danger of pressure sores. The bandage is soaked 
and squeezed in the same manner as has been described in the making 
of plaster splints, a second bandage being placed in the water at the 
time the first is removed. The bandage should be moderately wet 
when applied, and in cases where the center of the roll shows dry 
spots (this is always due to the bandage being rolled too tightly), the 
portion showing the dry spots should be cut off and discarded. 

The bandage must be applied immediately over the wadding in the 
same manner as any roller bandage, except that no tension must be 
exerted, and the application must be made smoothly and evenly. 
When irregularities become evident in the simple spiral turn they 
disappear either by slightly changing the direction of the bandage or 
by folding the bandage slightly upon itself, forming a "dart," which 
lies smoothly upon the surface. By a combination of spiral turns, 
figure-of-eight turns and darts, any portion of the injured part may 
be smoothly and evenly covered. As the bandage is applied, espe- 
cially as secondary turns cover the first, it should be well rubbed in a 
circular direction, in some cases adding a little dry plaster, and in 
others wetting the hand just before rubbing the plaster, as may be 
indicated. 

When the second bandage is applied the turns should take a differ- 
ent direction from the first, and as successive layers are applied they 
should be thoroughly rubbed with the hand. This tends to incorpo- 
rate the various layers and prevents their separation. The rubbing 
should be carefully attended to for the hardness and strength of 



56 FRACTURES IN GENERAL 

the plaster east is to a large extent dependent upon the thoroughness 
of the rubbing during its application. 

The thickness of a circular splint depends upon the uses to which 
it is to be put. For ordinary purposes a thickness of one-eighth of 
an inch is sufficient; while in certain instances, such as ambulatory 
cases, a splint half an inch thick may be required. Most splints made by 
unskilled workers tend to be too thick rather than too thin. They 
are especially likely to be uneven in thickness, certain portions upon 
which there is no undue strain being several times too thick. Con- 
sequently the beginner should endeavor to apply the bandage evenly, 
reserving any special thickness for portions upon which extra strain 
is likely to come. The aim should be a maximum of strength with a 
minimum of bandage. Too heavy casts are often a burden to the 
patient, and in some cases the mere weight of a heavy splint is suffi- 
cient to drag the fractured bone into malposition. 

When the last bandage is applied the surface may be smoothed off 
by the application of liquid plaster of Paris which is made by mixing 
the dry plaster with water to form a thin paste. This may be rubbed 
evenly with the hands over the bandage, and smoothed off by rubbing 
with wet hands after it has begun to dry. When the plaster is partially 
dry it is the practice of some surgeons to dust it well with dry talcum 
and then to smooth it with the hands until a glazed surface results. 
This glazed surface is especially desirable whenever the cast is likely 
to become wet or soiled by urine, perspiration, etc. 

During the application of the bandage the limb should be held in 
the position which it is desired to maintain. This position should 
be continued until the plaster sets firmly (usually twenty to thirty 
minutes), and no pressure or tension should be placed upon the 
splint until it is practically dry. Drying takes from three to twenty- 
four hours, according to the thickness of the plaster. When the 
plaster is entirely dry it may then be covered with the clothing, or a 
bandage, if desired. 

Where there is the slightest danger of interference with the circu- 
lation it is better to split the circular splint down one side from top 
to bottom. 1 This can be done easily with a sharp knife before the 
bandage is dry, and allows for the relief of constriction without appre- 
ciable weakening of the splint. The underlying bandage, if present, 
may be cut with bandage scissors. The preliminary splitting makes 
the removal of the bandage for inspection much easier than if the 
cutting is delayed until later. Of course, when a circular cast is 
split in this manner it is necessary to hold it in place by a circular 
bandage or by adhesive strapping. In some cases the edges of the 
splint require trimming, or fenestra are required for the dressing of 
underlying wounds. This should be done before the plaster is dry, 

1 In fracture cases of the extremities we make it a rule to split every circular bandage. 
This is accomplished by the use of a piece of muslin placed next to the skin beneath all 
dressings and used as a guide. (See treatment of Colics' fracture). 



THE TREATMENT OF FRACTURES 57 

but after it has set. Usually in five to ten minutes after the com- 
pletion of the bandage the trimming may be begun. Scissors are 
rarely used, a sharp knife cutting through the partially hardened 
plaster without difficulty. The cut edges are likely to be a little 
ragged, but they are easily smoothed off with a little soft plaster. 
The openings should be large enough for dressing the wound without 
unduly weakening the splint. 

To Remove a Circular Splint.— Only two instruments are of use in 
removing a circular splint. One is a sharp-bladed knife and the 
other is a pair of extra heavy bandage scissors. The line along which 
the splint is to be cut is marked out by the point of the knife, which 
makes a scratch along the entire length of the splint. With a medi- 
cine-dropper or wet sponge this line is wet with water throughout 
its entire length. The knife is drawn along the line once or twice 
and the cut is filled by means of a thin trickle of water. It is then 
found that the wet plaster cuts fairly easily, the wetting process being 
repeated each time the knife reaches dry plaster. With experience 
it is very easy to tell when the knife passes through the plaster and 
strikes the dry cotton beneath. The plaster scissors are of value 
in the latter part of the process, cutting through a few strands which 
lie next to the cotton and in a position where further use of the knife 
might cause injury to the patient. Where it is desired to continue 
the use of the same apparatus the opening of the splint may be sprung 
apart and the splint removed from the limb. In these cases it is well 
to bind the rough edges with adhesive plaster; and in some cases 
where splints are to be worn for a long time to make holes in the edges 
for laces. If laces are not used the splint is reapplied and held in 
position by adhesive plaster or a circular bandage. 

Plaster jackets may be applied in the same manner as circular 
splints of the extremities. By the same process a plaster jacket of 
the chest and a circular splint of the upper extremity may be com- 
bined in one piece, as is necessary in the treatment of certain injuries 
to the arm and shoulder. 

The Thomas Splint. — During the recent war the Thomas splint, 
slightly modified, was widely used in the treatment of gunshot fractures 
of the extremities. The advantages of a splint of this type are that 
it may be quickly applied, it allows the wound to be dressed without 
removal of the splint, it permits traction of the limb, and it is an 
unusually convenient splint for cases requiring transporation. Three 
splints were furnished for the transportation of the wounded. The 
Thomas splint, the Murphy modification of the Thomas splint and 
the Jones arm splint. In the Murphy modification the bars are 
hinged to the rung, permitting the arm to hang by the patient's side. 
The Jones splint is practically a modified Thomas splint, so adjusted 
that the arm hangs by the side and the forearm is bent at a right 
angle. The chief advantage of the splint is that it allows traction to 
be applied to the leg or arm while the patient is being transported. 



58 FRACTURES IN GENERAL 

The traction may be secured by strips of diachylon plaster or by 
strips of canton flannel or muslin held to the limb by means of Sin- 
clair's glue. 1 This glue is less irritating to the skin than plaster and 
allows a more evenly transmitted traction on the part. It is applied 
to the skin with a brush or a gauze bandage, and the strips of flannel 
or muslin are bandaged in place while the glue is drying. Preliminary 
shaving is unnecessary, the glue being easily removed with warm 
water. In order to secure traction the strips are fastened to the 
distal end of the splint with an elastic band or a piece of rubber tubing. 

The Thomas splint is especially valuable in cases of fracture of the 
humerus as a temporary dressing to permit transportation of the 
patient and radiography of the fracture. In some fractures the 
Thomas-type splint successfully holds the bones in place after ordinary 
methods have failed. 

Other Forms of Splints.— Metals, such as tin and aluminum, as well 
as hard rubber, papier-mache and various other compositions, have 
been used for splints without any apparent advantage over wood or 
plaster. Manufacturers advertise, and presumably sell, carefully 
carved splints of assorted sizes, most commonly for fractures about 
the hand and wrist. They come in sets and must be fitted to the 
injured part. They are expensive and have few, if any, points of 
superiority over those which may be improvised for the occasion. 
Wire splints may be of value in a few special cases, such as fractures 
about the elbow and shoulders, but they have no advantages over 
molded plaster, and in most cases serve merely as a clumsy, inadequate 
makeshift. 

Restoration of Function.— While it is generally recognized that there 
is a period after which the injured bones do better with the aid of 
massage and passive motion, there is considerable difference of opinion 
as to the best time to begin. It is a common custom to remove the 
splints only at six- to ten-day intervals for examination of the parts, 
and to reapply them without any attempts at massage or motion until 
the bone is believed to be firmly healed. A case sometimes presents 
itself in which a plaster cast has been applied and allowed to remain 
without attention for from four to six weeks. This form of treatment 
is open to serious objections for three reasons: There are likely to be 
injuries to the limb due to pressure; the bone may become displaced 
during this period without the knowledge of the surgeon; and in 
many cases such treatment is likely to be followed by stiffness of the 
tendons and joints. Many cases of ununited fractures have been 
treated by a long period of fixation which has lead to the belief that 
the fixation in itself was a predisposing cause to the non-union. It is 
apparently proved from evidence at hand that slight motion between 
the fractured ends of the bone predisposes to the formation of callus 
and in turn to osseous regeneration. Moreover, the increased blood 

1 Sinclair's glue is made by dissolving in a double boiler 50 parts of glue in 50 parts of 
water and adding 2 parts of glycerin and 1 part each of calcium chloride and thymol. 



COMPLICATIONS OF FRACTURES 59 

supply which accompanies massage would presumably make for an 
increased bone formation. 

For the above reasons it is believed to be wise to begin massage 
comparatively early, that is, on the third or fourth day, and to repeat 
it every dav or at least everv other dav. This reduces swelling and 
increases circulation which in time tends to promote healing. During 
the early period only very light massage should be used— a mere 
stroking of the arm in the direction of the blood supply. 

As a result of war experiences, it has been claimed that fractures 
about the joints are less often followed by stiff joints when slight 
active motion is allowed from the first day. In this form of treatment 
the splint is removed daily and the patient encouraged to move the 
joint a little, the amount of movement being increased daily a few 
degrees in each direction. Very excellent results have been reported 
in fractures about the knee, but there is insufficient evidence available 
to justify the use of active motion in all joint fractures. As soon as 
the bone is reasonably firm the patient should be encouraged to use 
the limb for easy movements. The longer the muscles are idle the 
greater the atrophy and the longer the period required for restoration 
to normal. 

COMPLICATIONS OF FRACTURES. 

These are classified as general and local, and may follow imme- 
diately after the injury or occur only after a period of days or weeks. 

General complications are shock, which is no different from shock 
from any other cause; fat embolism, which gives symptoms of edema 
of the lungs, and sometimes ends fatally; delirium tremens in alco- 
holics; and pneumonia, which occurs usually about the third day in 
young adults, or in the hypostatic form as a late complication in 
the aged. 

Local complications include injuries to the soft parts, fibrous changes 
in the muscles and joints and abnormalities of repair. 

Compound Fracture.— If there is a wound of the soft parts which 
allows communication between the fractured bones and the air the 
fracture is said to be compound, irrespective of how the injury was 
obtained. The fracture may be compounded from without, as by 
puncture or incised wounds; or from within, by the laceration of the 
tissues through the medium of the jagged end of the fractured bone. 

As there is a possibility of bacteria being introduced through the 
opening to the region of the broken ends of the bone, the indications 
are to prevent infection insofar as we are able. In these cases the 
prevention of infection is of far more importance than the reduction 
of the fracture, and having this in view, the limb should be manipulated 
as little as possible, attention being devoted chiefly to the condition 
of the wound. 

In practice it has been found best to swab out the wound with 3 
per cent tincture of iodine and to apply a dry dressing. Upon no 



60 FRACTURES IN GENERAL 

condition should the wound be probed, and a wet dressing is absolutely 
contra indicated in the early treatment. If the wound remains clean, 
infrequent dressings with careful attention to asepsis will tend to keep 
it from infection. Should infection occur free drainage should be 
instituted and continuous wet dressings applied. The greatest 
danger of infection is in the first few days after injury. After this 
period there is apparently set up at the point of injury a protective 
barrier which is moderate!}' effective against the rapid spread of 
infection. Consequently, if manipulation is desirable in a compound 
fracture it is better to wait for four or five days before attempting it. 
In gunshot wounds or other compound fractures, where infectious 
material is almost certainly introduced into the wound, it is con- 
sidered advisable to open the wound widely and remove all crushed 
and lifeless tissue, including loose fragments of bone. 

Hemarthrosis and Traumatic Arthritis are frequently complications 
of fractures near joints. They give their characteristic symptoms 
and require no special treatment except rest. Occasionally, effusion 
into the joint persists after the healing of the bone and causes con- 
siderable interference with function. In these cases the treatment, 
after the repair of the bone injury, is the same as in ordinary traumatic 
synovitis. 

Hematoma. —Rupture of a large bloodvessel, with a resulting hema- 
toma, is an infrequent complication. Cases have been reported 
where gangrene has followed interference with circulation in the limb. 
Such cases must be very rare. 

Paralysis.— The nerves may be injured and paralysis result, either 
at the time of original trauma or in the process of manipulation. 

After several weeks have elapsed a later form of paralysis may 
result from the pressure upon the nerve by the formation of callus. 
If there is no contraindication a ruptured nerve should be exposed 
and sutured about the end of the first week. Paralysis due to callus 
pressure should be relieved as soon as evident by incision into the 
callus and careful separation of the nerve. To prevent the possibility 
of recurrence the nerve should be anchored at some distance from 
the mass of callus. 

Ischemic Contraction is a name given to a peculiar type of paralysis 
due to fibrous changes in the muscles. It is a sort of interstitial 
inflammation and has been variously ascribed to venous stasis due to 
trauma, to nerve injury and to the circular constriction caused by 
tight bandaging. This much is certain. It is rarely, if ever, seen 
in those hospitals where care is taken to prevent constriction of the 
limb during the early period of edema of the soft parts. It usually 
occurs early and is accompanied by severe pain. The treatment 
consists of preventing constriction of the limb and increasing the 
blood supply by massage and passive motion. In late cases division 
of the contracted muscles may be required. 



COMPLICATIONS OF FRACTURES 



61 



Stiffness of the Muscles and tendons often occurs in cases where 
there is no definite contraction. This is usually due to the prelimi- 
nary edema, which is followed by adhesions in the muscles and tendon 
sheaths. In some cases the fear of pain is so great that the limb is 
held stiff for months after the injury. The treatment is preventive 
only, and consists of early passive motion and massage. In late 
cases, where stiffness of the muscles and tendons has occurred and 
where there is little improvement the fibrous bands should be broken 
up under general anesthesia. Following this, the muscles and tendons 
must be used daily to prevent the recurrence of adhesions. 

Thrombosis and Embolism. — 
Thrombosis of the veins surrounding 
a fracture has been described, but, 
except in compound fractures, it is 
probably very rare. If the vein 
is sufficiently large embolism may 
occur; indeed, unsuspected emboli 
may be the cause of some of the 
cases of pneumonia seen after frac- 
ture. 

Delayed Union, or failure of union, 
signifies a condition in which bony 
union is incomplete after a period 
considerably longer than would 
be ordinarily required for repair. 
Recognizing that certain general 
conditions, such as syphilis, preg- 
nancy, malnutrition and acute 
diseases, may be factors in de- 
layed union, the patient's general 
condition should receive appro- 
priate attention and treatment. In 
addition to this it is well recog- 
nized that interference with the nerve 

and blood supply will frequently delay union for a long period. Such 
cases are greatly benefited by systematic massage and passive motion. 
If, after the usual period, bony union is not complete, it is a wise 
procedure to remove the splint and allow the patient moderate func- 
tional use of the part. The results of this plan are often most strik- 
ing. In one case of non-union of the radius and ulna, after two open 
operations had been performed, there was only fibrous union, result- 
ing in a false point of motion in the middle third of the forearm. As 
there was no apparent improvement from week to week, the splints 
were removed and the patient told to use the arm as much as he was 
able, with the result that in three weeks he had firm bony union. 
Early massage is an effective means of preventing delayed union, 
and in cases where it is instituted and carefully carried out delayed 
union rarely, or never, occurs. 




Fig. 24. — Chronic osteomyelitis 
following compound fracture of three 
years' duration; no disability; firm 
union of both bones. 



62 FRACTURES IN GENERAL 

Faulty Union, or vicious union, is the name given to eases in which 
either following treatment or in the absence of treatment the bones 
heal irregularly with a resulting deformity. If the deformity is so 
slight as to be without significance, it is never spoken of as a faulty 
union. 

The treatment depends upon two factors: (1) The amount of 
deformity; (2) the degree of interference with function. If function 
is good, even when there is deformity, it is often not wise to attempt 
correction. If the deformity is very slight and there is considerable 
impairment of function the loss of function may or may not be due 
to the deformity, and care should be exercised before further attempts 
at reduction. Finally, in children faulty union is often corrected 
through the natural process of bone growth alone. In a certain 
number of cases the deformity is such that refracture or open operation 
is decided upon. It is difficult to give any rules for refracture. Cer- 
tain fractures, such as epiphyseal fractures in children, should never 
be allowed to remain in faulty position; others, such as fractures of 
the neck of the femur in old persons, should never be refractured. 
Each case must be judged on its merits; but, in general, if a good 
functional result is obtained it is usually wise to let well enough alone. 

If refracture is decided upon there is a choice of three methods: 

1. Manual Correction .—This is only possible in comparatively recent 
fractures. Angular displacement can often be corrected up to three 
or four weeks after the injury. If there is overriding that has per- 
sisted for more than a week or ten days very little can be done 
by manual methods. As little trauma results, this method can be 
attempted for slight indications during the first few weeks. However, 
repeated attempts at manual reduction tend to increase fibrous 
changes in the surrounding tissues, thus increasing the probability of 
tendon and joint stiffness. This is worthy of consideration in making 
a decision between manual reduction and open operation. 

2. Instrumental Correction.— Until recently fracture, by means of 
specially designed osteoclasts, was a common procedure. These 
forms of apparatus were often very powerful and the application of 
the force could be accurately controlled. Recently they have been 
less frequently used, the preference being given to an operation. 

3. Osteotomy.— Osteotomy serves the same purpose as osteoclasis, 
but allows accurate observation of the parts. Angular displacement 
may be corrected by the removal of a wedge-shaped piece of bone 
from the convex side of the angle, while overriding may be corrected 
by removing the overriding portion of the bone. As this is an opera- 
tion upon healthy bone, special attention to asepsis is absolutely 
indispensable. Simple osteotomy is performed by making a longi- 
tudinal incision along the bone where the projection is most prominent. 
After exposing the bone it is cut a little more than half way through 
with a sharp chisel and the remaining portion fractured manually. 
Usually the periosteum on the opposite side of the bone is firm enough 
to hold the fractured ends together. Special care should be exercised 



COMPLICATIONS OF FRACTURES 



63 



regarding asepsis. Even the gloved hand should not be introduced 
into the wound, and the portions of the instruments which enter the 
wound should not be handled by either the surgeon or his assistants. 
Deep sutures and ligatures should be avoided, the wound being held 
together by a single layer of superficial sutures. 

In cases of delayed union and faulty union the question of the 
advisability of open operation comes up. A few years ago the open 
operative treatment of fractures had many advocates. Fragments 
were nailed, rivetted, plated and spliced together. The results were 
in many cases so disastrous that few surgeons now use the open opera- 
tion until after the closed methods have been given a prolonged trial. 
When the open operation is used autogenous bone plates have, to a 
large extent, taken the place of metal plates. 




Fig. 25. — Inversion of foot following untreated defracture, causing marked disability; 

corrected by open operation. 

The operative treatment of fractures requires the utmost attention 
to technic and a highly specialized training in bone surgery. It 
should never be attempted except in well-equipped hospitals where 
methods of sterilization and operative technic are especially developed 
for this class of work. Therefore, the technic and discussion of 
these methods are out of place in minor surgery. 

Roentgenographs Control.— The best means available for the control 
of the treatment of fractures is the roentgenographic examination 
of the position of the bones. Except in fissure fractures and others 
showing little or no displacement, a roentgen-ray examination should 
be made after the fracture has been reduced and the splint applied. 
Pictures should be taken as frequently as is necessary to verify the 
position and to note the course of repair. The roentgenograph may 
be taken without removing the splint and with a minimum of incon- 
venience to the patient. For this purpose the portable bedside unit 
so efficiently used in the Army hospitals may be employed advan- 
tageously. 



CHAPTER III. 

INJURIES TO JOINTS. 

Of the injuries to joints, both from an anatomical and a clinical 
viewpoint, dislocations are the most important. 

DISLOCATIONS. 

Statistics show that approximately 90 per cent of all dislocations 
occur in the upper extremity. As a consequence, most cases occur 
among out-patients, that is, patients who are able to walk to the 
surgeon's office or to the surgical dispensary. It is essential, therefore, 
that the practitioner who is called upon to treat minor surgical con- 
ditions shall have, not only a knowledge of dislocations in general, 
but also a clear understanding of the various varieties of the different 
dislocations of the upper extremity. 

A dislocation is a more or less permanent abnormal displacement 
of the articular surface of one of the bones in its relation to the other 
articular portions of the joint. As such an injury presupposes the 
forcible overcoming of the normal restrictions of the joint movement, 
the injury is practically always accompanied by the tearing or rupture 
of some portion of the ligament about the joint. In some cases there 
is also injury of the intra-articular cartilages or the bony margin of 
the joint surface. There is almost always hemorrhage into the joint 
and a certain amount of traumatic synovitis due to injury of the 
synovial membrane. 

Symptoms.— The signs of recent dislocation may be tabulated as 
follows : 

Subjective: 

1. Pain. 

2. Loss of function. 
Objective: 

3. Swelling. 

4. Ecchymosis. 

5. Deformity. 

6. Tenderness. 

7. Loss of mobility. 

8. Roentgen-ray findings. 

1. Pain.— Pain is a constant symptom of dislocation. It is acute 
and likely to continue for some time with unabated severity. It is due 
in part to the laceration of the ligaments and in part to the tension 



DISLOCATIONS 



65 




Fig. 26. — Dislocation of little finger, recurrent after two weeks' fixation or flexing finger. 




Fig. 27. — Fracture of neck of humerus simulating subcoracoid dislocation. 



G6 



INJURIES TO JOINTS 



upon the surrounding tissues. The pain from the latter cause is 
relieved, to a large degree, as soon as the dislocation is reduced. 

2. Loss of Function.— The function of the joint is usually com- 
pletely lost immediately after the accident, while in a simple fracture 
about the joint the function is usually retained. 

3. Swelling. — After several hours there is likely to be considerable 
swelling in the region of the joint. This swelling is usually somewhat 
modified by the protrusion of the dislocated bone. 

4. Ecchymosi s.— Ecchymosis may, and usually does, occur in disloca- 
tions. It is commonly late in making its appearance and has little 
or no special significance. 




Fig. 28. — Inward dislocation of great toe giving symptoms and appearance of acute 

bunion. 



5. Deformity.— Deformity is an important symptom in dislocation, 
each dislocation having its characteristic deformity. In joints, which 
are not too thickly overlaid by soft parts, the dislocated part of the 
bone may be easily felt beneath the surface. The limb may be actu- 
ally shortened or lengthened, but the value of this sign is diminished 
because of the inability to place the limbs symmetrically. Mensura- 
tion has the same disadvantages that have already been noted in the 
discussion of fractures 

In some cases the empty joint cavity can be distinctly felt by 
the examining finger. In almost every dislocation there is the cor- 
responding characteristic attitude which will be discussed in detail 
under individual dislocations. 

6. Tenderness.— Tenderness is a constant symptom of dislocation. 
It is present over the lacerated soft parts and over the dislocated 




Fig. 29. — Habitual dislocation. Roentgenograph shows the abnormal mobility of 

joint caused by relaxed capsule. 




Fig. 30. — Inward dislocation of first metatarsal bone with fracture of second, third and 

fourth, 



68 INJURIES TO JOINTS 

bone where the tissues are held tense. It is diffuse and has no special 
characteristics. Tenderness is of much less value in the diagnosis of 
dislocation than it is in fracture. 

7. Loss of Mobility.— The motions of the joint show limitation in 
every case, except where there is extensive laceration of the capsule, 
in this latter type passive motion is through an abnormal arc and is 
not as free as the false motion of fractures. Usually motion toward 
the uninjured ligament is free, while motion in the opposite direction 
is limited by the attachments of the untorn ligaments. 

8. Roentgen-ray Findings.— While the roentgen ray is of value in 
dislocation, it is of considerable less value than in cases of fracture. 
It is frequently very difficult to say positively that a dislocation exists 
simply from the examination of the roentgen-ray negative. However, 
it is occasionally of great value and in doubtful cases the roentgen-ray 
examination should never be omitted. It meets its greatest indica- 
tion in the differential diagnosis between luxation and fracture. 

COMPLICATIONS OF DISLOCATION. 

Fracture of any of the bones entering into the articulation may 
complicate dislocation and require special treatment. Fractures of 
a small portion of the articulating surface or at the attachment of the 
ligament to the bone occur frequently in association with dislocations 
and are essentially a part of the dislocation and have no special sig- 
nificance. In other cases the shaft of the bone at some distance from 
the joint may be broken by the same trauma which causes the luxa- 
tion. Such an accident adds greatly to the difficulty of reduction 
which may be impossible except by open operation. 

Injury to the Bloodvessels and nerves may occur as a complication 
of dislocation and gives rise to characteristic symptoms. Except in 
the larger joints such injuries are rarely severe enough to require 
special treatment. Stimson has collected 56 cases of rupture of the 
axillary artery as a complication of dislocation of the shoulder, in 
which 33 terminated fatally. This injury, while rare, should be 
suspected if, after reduction or attempts at reduction, there is inter- 
ference with the blood supply of the arm. The diagnosis is confirmed 
if in addition there is the presence of a fluctuating tumor in the axilla. 
In one case seen by us the patient showed less disability than might 
have been expected. There was a large elastic swelling about the 
shoulder, but the pulse was still present and the patient was not 
markedly prostrated. 

Both fracture of the surrounding bones and injuries to the soft 
parts may result as an accident of reduction as well as a complication 
of the primary injury. 

Habitual Dislocation is usually the result of extensive injury to 
either the capsule or joint surfaces and of inefficient treatment at the 
time of the original injury. Thus, if a patient is allowed to use a 



TREATMENT OF DISLOCATION 69 

joint freely before the capsule has healed a second dislocation may 
easily result; and this accident, several times repeated, results in a 
permanent lack of support in the joint capsule which easily permits 
recurrence of the dislocation. In a somewhat similar manner exten- 
sive lacerations of the capsule or fractures with displacement of por- 
tions of the articular surfaces may so weaken the normal strength 
of the articulation as to permit easily recurrent dislocations. In a 
few cases fixation of the joint for a long period may successfully pre- 
vent recurrence; while in others operative interference and suture 
of the capsule may be necessary before there is a permanent cure. 
However, in many cases the habitual dislocation causes little incon- 
venience, the patient learning to reduce the deformity easily and 
without pain. Unless the frequency of the accident seriously inter- 
feres with the patient's ability to earn a livelihood, interference is 
not indicated. 

Compound Dislocation sometimes occurs, though much less frequently 
than compound fracture. The danger of suppurative arthritis, 
especially in large joints, is very great. In these cases the treatment 
of the infection of the joint is of far more importance than the dis- 
location. The treatment of joint suppuration will be discussed in 
detail under Wounds of the Joints. 

Subluxation is the name given to a partial dislocation. It is usu- 
ally caused by a stretching of the capsule which permits the articu- 
lating end of the bone to slip part way out of the socket. The bone 
usually rests a moment on the rim of the articular cavity and then 
slips back into place. Many persons can voluntarily cause a sub- 
luxation of the metacarpophalangeal joint of the thumb. In some 
cases a joint may show permanent subluxation. Reduction is usually 
easy, except in cases where a new cavity has been formed or where 
muscular contraction prevents reduction. 

TREATMENT OF DISLOCATION. 

The treatment of dislocation, like that of fracture, consists of: 

1. Reduction. 

2. Retention. 

3. Restoration of function. 

1. Reduction. —There are two methods of reduction: (a) Traction, 
which has only a limited value ; (b) manipulation. Traction is exerted 
in the long axis of the limb and will occasionally result in prompt 
reduction. It does not, however, take into consideration the pathol- 
ogy of the particular dislocation, and it is likely to be painful and 
ineffectual. In general, if manipulation fails reduction by manual 
traction may be attempted. It is hardly necessary to say that trac- 
tion by means of apparatus has long since been abandoned in the 
general treatment of dislocation. However, traction by means of 
weights so applied as to tire out the muscles about the joints is still 



70 INJURIES TO JOINTS 

occasionally used in the reduction of dislocation of the shoulder 
(Stimson) . 

Reductive manipulation aims at making the displaced hone retrace 
the steps it has taken in the process of dislocation. It is based upon 
the attachments of the muscles and ligaments, especially the latter, 
and on the location of the rent in the capsule. The steps vary with 
the different dislocations and will be taken up when these dislocations 
are discussed. 

Anesthesia is frequently unnecessary for reduction of dislocation. 
It is required especially in muscular individuals, where the involun- 
tary contraction of the muscles due to the acute pain is, in itself, an 
obstacle to reduction. Nitrous oxide is the safest anesthetic and 




Fig. 31. — Congenital dislocation of hip; later developed tuberculosis. Cured with 
ankylosis. Fracture of reserve date firm review. 

should receive a trial if an anesthetic is required. Occasionally the 
more complete relaxation of ether anesthesia is desirable. Local 
anesthesia has been used for dislocations about the wrist and hand. 
Its use requires an accurate knowledge of the nerve supply, and it is 
neither less dangerous nor more convenient than nitrous oxide. 

2. Retention.— Retention is of much less importance than in the 
case of fracture. Once reduced, the dislocated bone usually tends to 
remain in place if the movement of the joint is limited. It is well to 
prevent extreme movements of the joints for at least ten days. This 
can be accomplished often by means of a bandage or light splint. 
Adhesive-plaster dressings, such as will be described under Sprain*, 
are frequently of great value during the after-treatment. 



TREATMENT OF DISLOCATION 



71 




Fig. 32. — Club-feet untreated. 




Fig. 33.— Club-feet, same case as shown in Fig. 32 after treatment, able to wear ordinary- 
shoes. 



72 INJURIES TO JOINTS 

3. Restoration of Function. —Restoration of function is accomplished 
by active motion and massage begun on the second day, care being 
taken not to cause the dislocation to recur. The pain and tenderness 
about the joint persist in some cases for weeks and months after the 
injury. In other cases, especially in recent dislocations, the pain 
ceases within a few hours after the bone has been reduced. 

Old Dislocations. — After dislocation has existed for a period of a 
few weeks or longer changes gradually set in, both in the bones mak- 
ing up the articulation and in the soft parts. The head of the bone 
becomes atrophied and the joint cavity becomes filled with fibrous 
tissue, while there are degenerative changes in the bones as well as 
in the surrounding muscles, arteries and nerves. While it is impos- 
sible to fix definitely the time limit after which a dislocation cannot 
be reduced, it is safe to say that reduction is exceedingly difficult 
after the first week; almost impossible after two or three weeks; and 
and if the period of dislocation has been much longer than this, attempts 
at reduction by manipulation are contraindicated. 

Open operation for old dislocations, with excision of fibrous tissue 
and resection of portions of the bone which interfere with move- 
ment, is frequently successful, though restoration of function is apt 
to be incomplete. 

Congenital Dislocations. — Deformities of the joints in children may 
be due to congenital dislocation. They occur most frequently in the 
hip and rarely in the shoulder- and elbow-joints. The treatment is 
highly specialized and is found in the various works on orthopedic 
surgery. 

SPRAINS. 

There is at present some confusion in the use of the word "sprain." 
Thus, we find the terms "muscle sprain," " tendon sprain" and "joint 
sprain" used frequently in medical literature without a very clear 
conception as to the author's meaning. It is sometimes used inter- 
changeably with the word "strain." 

The term "sprain" usually refers to an injury in the region of a 
joint. Its use should be limited to the injury caused by the forcible 
stretching, with partial or complete rupture, of one or more of the 
ligaments of the joint, without dislocation. It is, usually caused by 
a force which tends toward dislocation, but which is arrested before 
the luxation is complete. It follows from this that the torn condition 
of the ligament after the reduction of a dislocation is essentially a 
sprain. 

Associated with the torn ligament common to all sprains, there is 
likely to be effusion and hemorrhage into the joint and edema of the 
overlying soft parts. 

Symptoms.— The symptoms depend somewhat upon the amount of 
effusion into the joint and upon the degree of laceration of the liga- 
ments. A mild sprain may consist of the rupture of a few fibers 



SPRAINS 73 

only and may show few symptoms. In a moderately severe sprain 
the symptoms are typical, resembling closely those of fracture near 
the joint. 

The acute pain of sprain at the time of the injury is often very 
severe, and for a few minutes there may be complete loss of function. 
Following this, if the patient avoids putting the injured ligament 
upon the stretch, function of the joint is possible to a moderate degree. 
Thus, a patient with a sprained wrist may play tennis for several 
hours with only moderate discomfort; and the ordinary history of a 
sprained ankle is that the patient was able to walk for a considerable 
distance after the accident, only to become disabled later because 
of pain and swelling. In fracture, on the contrary, this period of 
fairly normal function is usually absent; and the mere fact in the 
history of an ankle injury that the patient was able to walk after 
the accident is presumptive evidence of sprain. Several hours after 
a severe sprain there is considerable swelling of the soft parts and 
probably also effusion into the joints, together with a proportionate 
increase of pain and loss of function. Disability continues with 
diminishing intensity for several days. 

The chief objective symptoms are swelling, ecchymosis, tender- 
ness and abnormal mobility. The swelling is of two types: the joint 
swelling and the swelling of the soft parts. The former, caused 
by the distention of the joint cavity, is sometimes so characteristic 
as to be easily identified, as for example in the knee-joint; while the 
latter is usually diffuse and apt to be most prominent in the region 
immediately adjacent to the torn ligament. In most cases the two 
types are combined so that they cannot be distinguished, the joint 
swelling being identified very early or after the superficial swelling 
has subsided. 

Ecchymosis usually appears early. It is identical with the ecchy- 
mosis in fracture, except in its point of origin, and consequently has 
no significance in differential diagnosis. 

Tenderness is as important in the diagnosis of a sprain as it is in 
fracture. In addition to this, the location of the tenderness has an 
important bearing upon the differential diagnosis between the two. 
There are two varieties of tenderness— a diffuse tenderness over the 
area of swelling and a localized tenderness over the site of the torn 
ligament. The localized tenderness is acute and similar to the winc- 
ing tenderness of fracture, but it is located over the ligament rather 
than over the bone. Thus, given an injury about a joint, acute 
tenderness over any portion of a ligament or its attachment points 
to sprain rather than fracture. Another point in the differential 
diagnosis is that in fracture the tenderness is likely to be present on 
both sides of the bone, because the fracture passes through the bone; 
while in sprain it is on one side only, that is, over the site of the torn 
ligament. 

In sprain pain may be elicited indirectly by movements which 



74 INJURIES TO JOINTS 

put the injured ligaments upon the stretch, while the passive motion 
of the joint in the opposite direction may be painless or nearly so. 

Abnormal mobility is rarely demonstrable in sprain; but when 
present, it has considerable diagnostic significance. It is a result of 
the lack of normal ligamentous restriction of motion. It may be an 
increase of the normal motion of the joint, such as increased inver- 
sion of the ankle after rupture of the external lateral ligaments; or it 
may consist of a joint motion which is usually absent, such as lateral 
angulation at the knee after rupture of the ligaments. In most 
cases, however, abnormal mobility is so slight as to make its demon- 
stration exceedingly difficult. 

Treatment. —There is a choice of two different plans in the treatment 
of a sprain. In the first plan the treatment consists of a preliminary 
period of rest during which the swelling is limited by cold applications 
or a tight bandage, followed after two or three days by passive motion 
and massage, the joints being supported between the periods of 
massage by a light splint. In no case should the fixation be perma- 
nent, for this is almost certain to result in adhesions which in turn 
cause prolonged convalescence. The advantage of this method is 
that the pain is lessened from the start; but it has many disadvan- 
tages, among which are the long periods of disability and the healing 
of the injured ligament in a relaxed condition. It must be empha- 
sized that to secure satisfactory results from this method, passive 
motion and massage must be performed daily for a long period. 

The second plan which is preferable in the majority of cases, consists 
of support of the ligament and the joint by a heavy adhesive-plaster 
dressing which is so applied as to cover the limb from a point several 
inches above, in the case of the larger joints, to a corresponding point 
below. It is best applied in the form of narrow, overlapping strips, 
one-half inch in width and long enough nearly to encircle the limb. 
These strips are put on firmly so as to exert pressure, and where the 
strain is greatest they may be arranged so as to be two or three layers 
in thickness. Application is made as soon as the patient is seen, if 
possible before the swelling has become extensive, care being taken 
that the limb is not entirely encircled by the adhesive-plaster dressing. 
If a space of an inch or more is left between the ends of the adhesive 
plaster, there need be no fear of constriction of the limb. 

The patient is advised to use the joint moderately the first day, 
and encouraged to use it freely after twenty-four hours have elapsed. 

If there has been considerable swelling the strapping will become 
loose in four or five days and require the application of a new dressing. 
If this does not occur the adhesive plaster may remain for from seven 
to ten days. It is then removed, the skin cleaned well with alcohol 
and a similar dressing applied. In moderately severe sprains this 
must be repeated about the end of the second week. After three or 
four strappings the ligament may be expected to be firmly healed 
and the patient is encouraged to use the joint without support. How- 



TRAUMATIC SYNOVITIS 75 

ever, in some cases, as for example in sprains about the knee, some 
method of support may be required for several months or longer. 

The advantage of strappings over other methods is, in the main, 
the short period of disability. Besides this, the swelling is prevented 
to a certain degree, as a consequence of which the torn ends of the 
ligaments are kept in better approximation and healing is more rapid 
and complete. Functional use of the joint, which is partially encased 
in a firm support, causes a species of automatic massage which, in 
turn aids the blood supply and decreases the duration of the period 
of repair. 

While the application of suitable adhesive-plaster dressings requires 
considerable time, the number of visits is usually considerably lessened 
and the satisfaction of the patient, on account of the short period of 
disability, is greatly increased. Stiffness never follows this plan of 
treatment. 

It should be remembered that in practically every sprain there is 
an associated traumatic synovitis of the joint which may prolong 
the period of disability for weeks or months. Clinically this occurs 
very frequently in cases of sprain of the knee-joint, and only occa- 
sionally in other joints. 

Sprain-fracture. — This term is sometimes used to indicate a sprain 
in which the ligament is intact, but in which a small piece of bone at 
the attachment of the ligament has been torn away. 

If the portion of bone is small (usually a mere sliver of the bone 
and periosteum) the condition is essentially a sprain and should be 
treated as such. 

In some cases the fragment of bone may be of considerable size and 
show displacement of an inch or more. When such a fragment is 
large and gives the other symptoms of fracture the condition is a 
true fracture and should be treated as such. The roentgen ray is a 
valuable aid in the diagnosis of sprain-fractures. 

Operation, which consists of exposure and suture of the torn liga- 
ments, is occasionally necessary in cases of sprain or sprain-fracture. 
If, after several weeks, the joint remains weak and insecure (and this 
is especially likely to occur after rupture of the lateral ligaments of 
the knee-joint), open operation is justified. In sprain-fracture opera- 
tion is sometimes required on account of inability to reduce the dis- 
placed fragment. In such cases it is best to perforin the operation 
during the first week after the accident. 

TRAUMATIC SYNOVITIS. 

While to a greater or less extent traumatic synovitis accompanies 
all sprains and dislocations as well as fractures involving joints, it is 
generally overshadowed by the more important lesion of which it is 
considered a concomitant part. Occasionally, however, the sole 
apparent result of a trauma is the effusion into the joints; while in 



76 



INJURIES TO JOINTS 



other cases the joint effusion persists for a considerable period after 
the injuries to the bones or the ligaments have apparently undergone 
complete repair. 

Symptoms.— The most striking symptom of synovitis is effusion into 
the joint which, when extensive, gives rise to pain and loss of function. 
The swelling follows the outline of the synovial cavity. In the super- 
ficial joints the fact that the fluid is within the joint is easily recog- 
nized. In the case of some joints, for example the hip, the overlying 
parts are so thick that it is often difficult to determine whether or 
not there is fluid present. In a few cases, even in the absence of any 
wound of the overlying skin, suppuration may supervene during the 
course of what was apparently a simple traumatic synovitis. 




Fig. 34. — Traumatic synovitis of left knee in painter, aged forty-four years. Large 
gouty bosses on shins and knees containing chalky material. 

Treatment. —The treatment consists of rest and cold applications 
during the acute period. It is important to remember, when the 
effusion is at its height, that the cavities of most joints are, as a rule, 
of the greatest capacity when the joints are in a semiflexed position. 
As a consequence, if splints are required the plaster splints, already 
described under fracture, are the most easily adapted to the flexed 
position of the joint. After the subsidence of the acute symptoms 
the functional use of the joint tends to aid the absorption of the 
effused fluid if the joint is protected against further injury. This is 
best accomplished by means of adhesive-plaster strapping as recom- 
mended in the treatment of sprain, the patient meantime being 
allowed to use the joint. In addition to this, or in some cases as the 
only treatment, regulated exercise and systematic massage aid materi- 
ally in recovery. 

Aspiration of the joint may be required in chronic cases; but it is 
well to remember that when aspiration is required there is often some 



WOUNDS OF THE JOINTS 77 

underlying cause other than simple trauma. The acute traumatic 
joint should seldom be aspirated. 1 

Aspiration should be carried on under the strictest aseptic precau- 
tions. The aspirating needle is inserted, attached to the syringe, 
into the cavity of the joint, care being taken not to injure the articular 
surfaces. When the needle is felt to move freely in the joint cavity 
the fluid is withdrawn by suction. It is useless to try to obtain the 
fluid without suction, as the pressure within the joint is never sufficient 
to expel more than a few drops of the effusion. After the fluid has 
been removed the joint should be bandaged tightly and freely moved 
in order to hasten absorption. 

In persistent cases, with thickening of the capsule so that the 
capacity for absorption is diminished, Whitman advises incision and 
the application of carbolic acid or tincture of iodine to the inside of 
the capsule, the aim being to lessen the irritability and to stimulate 
the reparative process. The prognosis in cases requiring operation 
is uncertain. 

Hemarthrosis may be caused by any of the injuries which result 
in traumatic synovitis. The swelling is more resistant and persists 
longer than the ordinary traumatic synovitis. If it were possible to 
make a positive diagnosis incision, with removal of the clots, might 
advisable. In some cases this has been done successfully; but usu- 
ally the diagnosis is so uncertain that operation is not justified. 

Hemarthrosis as a complication of hemophilia is not uncommon, 
the knee-joint being most often involved. Usually there is a history 
of trauma which is often very slight. The condition leads to joint 
changes which may be mistaken for tuberculosis. The chronic symp- 
toms consist of swelling, limitation of motion and deformity combined 
with weakness and discomfort. Secondary changes occur which 
resemble the early stage of hypertrophic arthritis. The treatment 
consists of rest and counterirritation, combined with adequate pro- 
tection of the joint. Operation is contraindicated, as fatal hemorrhage 
may result. 

WOUNDS OF THE JOINTS. 

Traumatic injuries may penetrate the joint, or the joint cavity 
may be opened in the course of an operation. In puncture wounds 
in the vicinity of the joint the escape of the serous joint fluid is proof 
positive that the joint has been penetrated. Clean wounds of joints, 
such as those occurring in the course of aseptic operations, should be 
closed tightly without drainage, and puncture wounds may be swabbed 
with tincture of iodine and allowed to heal. Should infection become 
evident and the discharge become purulent or seropurulent the joint 
should be widely opened and drainage instituted. A wet dressing- 
should be applied, being kept constantly wet with a 1 to 200 watery 

1 Recently, early aspiration has been advised in cases of synovitis of the knee. 



78 INJURIES TO JOINTS 

solution of tincture of iodine, or a saturated solution of boric acid. 
Dakin's solution may be used to irrigate the joint or for the wet 
dressing. Traumatic injuries with frank contamination of the wound 
should be treated as though infected from the start. All bruised 
and badly contaminated tissue along the tract of the wound should 
be excised. Joint cavities have only a slight resistance against 
pathogenic bacteria. In every case the joint is to be protected and 
put at rest by the use of an appropriate splint. 

Within recent years attempts have been made to prevent the 
development of experimental arthritis (after the injection of staphylo- 
cocci) by the immediate cleansing of the joint with antiseptics, such 
as iodine, carbolic acid solution, etc. The results of these experi- 
ments have not been promising, the infection being rarely prevented. 
The successful cases are those in which the antiseptic solution is used 




Fig. 35. — Eighty per cent normal function three years after gunshot wound of right 

hip-joint. 



immediately after the introduction of the bacteria. In human surgery 
the infection is usually well developed before it is seen by the surgeon; 
but upon the basis of animal experiments, a trial of the antiseptic 
treatment of traumatic injuries to joints would be justified in those 
cases in which there has been the introduction of foreign material 
into the wound. For this purpose 50 per cent alcohol or 2 per cent 
carbolic acid solutions have been advised. In war surgery Dakin's 
solution has been used in cases of this type with satisfactory results. 
It should be freshly prepared and used strictly according to the Carrel- 
Dakin technic. 

If a purulent arthritis develops the joint should be widely 
opened so as to allow free drainage. Rubber tubes were formerly 
inserted into the joint cavity, but it was found that they acted as 
foreign bodies and increased the irritation. It is better to avoid 



WOUNDS OF THE JOINTS 79 

any form of drainage within the joint itself and to confine the use of 
drainage material to the superficial wound. 

Gunshot Wounds. — Gunshot wounds of the joints are almost always 
associated with fracture. There are frequently numerous small 
particles of bone loose in the joint cavity and contusions and erosion 
of the cartilaginous surfaces. Often the bullet or other foreign body 
remains in the joint. The danger of infection depends upon the size 
of the wound, the amount of injury to the joint, the size and shape 
of the projectile, together with the amount of infectious material 
carried into the joint. Today it is recognized that a joint will care 
for a certain amount of infection, especially in the absence of foreign 
bodies. 

Diagnosis. — The diagnosis is based upon the location and appearance 
of the external wound and the direction of the tract made by the 
projectile. The joint is almost certain to be swollen and may show 
a discharge of sanguineous joint fluid. 

In a few cases there may be, in the case of a wound in the vicinity 
of the joint, an associated synovitis without penetration of the joint. 
In such cases where this condition is suspected the joint may be 
aspirated and the fluid examined microscopically. An increased 
number of leukocytes would indicate penetration and infection of 
the joint. 

Treatment.— Conservative treatment may be instituted in very 
small perforating wounds when there are no foreign bodies in the 
cavity of the joint. 

In most cases it is much better to excise the tract completely and 
to remove all the devitalized tissue as well as all loose particles of bone. 
The wound is then washed out with an antiseptic solution, such as 
Dakin's solution, using enough to flush the entire joint thoroughly 
and to remove mechanically as much infectious material as possible. 
The wound is left open for drainage; but drainage material is never 
introduced into the cavity of the joint. If infection occurs a counter- 
incision is made to allow additional drainage. In extreme cases of 
virulent infection amputation may be required. If there is severe 
pain the joint may be held fixed by means of a splint; and in the 
case of the larger joints traction may be applied. 

Recently Dr. Charles Willems, of Belgium, has done away with 
immobilization in cases of this type, except in those cases which 
require a splint to prevent the recurrence of serious displacement. 
Not only does he do away with immobilization, but, in addition, he 
obliges the patient to move his joint without delay. His method of 
treatment is described as follows: 1 "The patient furnished with a 
simple dressing, not too tight, is encouraged to make movements from 
the time he awakens from his anesthetic. He always obeys; if not 
at once at least after it has been insisted upon. As soon as he is 

1 Ann. Surg., February, 1919, 69, 212. 



80 INJURIES TO JOINTS 

convinced that motions are possible and not too painful he will con- 
tinue to make them without being asked to do so." 

Immediate active mobilization, according to his experience, gives 
an infinitely better prognosis and reduces muscular atrophy to a 
minimum. In cases complicated by marked effusion or hemarthrosis 
active motion is interfered with and aspiration of the joint is neces- 
sary. After aspiration the joint may be moved freely again. Passive 
motion is not used as part of the treatment. Infected joints are 
treated in the same way. 

The Willems' treatment of joint injury is of too recent origin to 
justify its universal application. It is highly recommended and will, 
without doubt, decrease the chances of fibrous ankylosis in certain 
selected cases of joint injury. The value of the treatment depends, 
in our opinion, upon the fact that it increases drainage from the joint 
and increases the blood supply to the joint. The use of this form 
of treatment does not invalidate the old principle of rest for infec- 
tions, but it does prove that rest is not sufficient unless free drainage 
is also provided. Without discarding the old method it should be 
possible to give enough motion to joints to allow for the maximum 
benefits from free drainage, without attempting the extremes of active 
and passive motion wmich might injure the parts. As a matter of fact, 
Willems insists upon "active" motion, so that there is always present 
the patient's natural impulse to protect the injured part. 



CHAPTER IV. 
INFLAMMATION, SUPPURATION AND GANGRENE. 

INFLAMMATION. 

Inflammation is the reaction of living tissue to some form of 
irritation. The irritation may be due to trauma, to chemical or ther- 
mic agents or to bacteria, in which case it is called infection. Surgi- 
cal inflammation is commonly caused by bacteria. Inflammation has 
been described as "the succession of changes which occur in living 
tissue when it is injured, providing that the injury is not of such 
a degree as at once to destroy its structure and vitality." It is asso- 
ciated with active hyperemia, usually a retardation of the blood 
flow, the exudation of the fluids of the blood into the tissue, and a 
migration of the white blood corpuscles through the vessel walls. 

Inflammation may be classified as acute or chronic, according to the 
course of the affection; as infective or simple, in accordance with the 
presence or absence of a microorganism as the exciting agent; as idio- 
pathic, traumatic, malignant, neuropathic, etc., according to the cause. 

Symptoms.— The symptoms are local and general. The local 
symptoms are heat, pain, swelling, discoloration and interference 
with function. The general symptoms are fever and toxemia of a 
varying degree, depending on the type of infection and the area of 
inflammation. In septic infections there is usually a well-marked 
leukocytosis. 

Surgically we usually have to do with inflammation due to some 
plainly apparent cause, such as a burn or an infected wound. How- 
ever, there are sometimes seen areas of inflammation in which the 
cause is obscure, and which becomes manifest only during the course 
of the disease. In such cases we are limited in our therapeutic meas- 
ures to treatment aimed at the relief of the inflammation as such, to 
the apparent neglect of the causative factor. Inflammation is a 
curative process in itself and tends to be self-limited, usually ending 
in recovery. 

Treatment.— The first indication in the treatment of inflammation 
is to find the cause and if possible to remove it. If it is caused by a 
foreign body, such as a splinter, the splinter should be removed; if 
it is due to an infected wound, drainage should be obtained without 
delay; if it is due to trauma, as from the irritation of a badly-fitting 
shoe, the cause of the trauma should be removed. If the cause of 
the inflammation has been only momentary in its effect, as from a 
blow or a burn, we cannot remove it, but we can prevent further 
6 



82 INFLAMMATION, SUPPURATION AND GANGRENE 

irritation increasing the injury. Thus, a man who has a burn on 
his neck is prevented from wearing a stiff collar until healing has 
taken place, in order to avoid irritation of the burned area. 

Two agents, which are of value in almost every type of inflammation, 
are rest and elevation. 

Rest may be secured by the use of a splint, by the support of the 
part on a pillow, or by rest in bed. The pain and swelling in them- 
selves tend to induce rest ; the pain acting to prevent voluntary action, 
and the swelling causing a certain amount of stiffness of the part. 
Whether complete rest is indicated in all kinds of inflammation, or 
whether certain types of inflammation, as for example that following 
trauma, will do better if mobilized from the start, is not definitely 
decided; but it is certain that inflammation due to infection does 
much better when placed at absolute rest, or nearly so. 

Elevation tends to reduce pain by diminishing the congestion of the 
part. This in turn decreases the swelling, and thus relaxes the ten- 
sion on the nerve endings which is the cause of the pain. A felon 
will throb and become more painful when held in a dependent position, 
and a toothache is often worse on lying down. Both of these condi- 
tions are relieved by elevation. In inflammation about the foot the 
pain is usually less when the patient is put to bed with the foot elevated 
on a cushion. 

Artificial hyperemia is of use in certain classes of inflammation, 
especially the chronic type. It increases congestion and should not 
be used in cases where there is already an overcongestion as evidenced 
by tense swelling and cyanosis. 

Two methods are employed to secure hyperemia: (1) The use of 
apparatus which acts chiefly by suction, as is seen in the cups intro- 
duced by Bier; (2) the use of a constricting bandage so applied above 
the area of inflammation as to obstruct the venous return and thus 
increase the blood supply. 

Bier's cups are made of heavy glass and are so constructed that a 
partial vacuum can be obtained in the cups by the use of either a 
rubber bulb or a suction pump. Bier's cups may be simple in con- 
struction, such as the small cup used for the treatment of a boil or 
small abscess, or they may be much larger and capable of applying 
suction to an entire leg or arm. They are usually left in place for an 
hour or more daily. 

Constriction hyperemia is obtained by the use of a bandage of the 
Esmarch type, by rubber tubing or occasionally by a simple muslin 
bandage. In using constriction to obtain hyperemia, the bandage 
should be applied proximal to the lesion and tight enough to prevent 
the venous return without preventing the flow of blood through the 
arteries. The constriction should never be firm enough to obliterate 
the pulse distal to the bandage. In the arm and thigh a wide Esmarch 
bandage is required in order to secure sufficient constriction without 
causing pain, For the fijig®r§ a strip of rubber tubing is sufficient, 



INFLAMMATION 83 

This constriction is applied on the first day from three to six hours. 
The next day the bandage is left on for twelve hours, and the time is 
gradually increased until the period of constriction is twenty-two hours 
in every twenty-four. This should not be exceeded. Some advise 
that the constricting bandage be allowed to remain for twenty-two 
hours the first day, if there is no pain. 

What cases of inflammation are to be treated by hyperemia? We 
believe that the best results are obtained in subacute or chronic 
cases, and during the healing stage of an acute inflammation. In 
Bier's clinic in Berlin this treatment was used at one time for acute 
cellulitis, such as is seen in an infected puncture wound of the palm. 
Hyperemia used in this manner is not indorsed, and should not be 
used to the neglect of recognized surgical therapy. If the constriction 
is left on for several hours the patient should be instructed to remove 
the bandage if there is severe pain or other sign of arterial constric- 
tion. 

Cold.— When properly applied cold applications are decidedly 
beneficial in the treatment of inflammatory processes. Because of 
the reflex effect on the vessels, possibly more than through its direct 
action, cold is one of the most useful agents which we have at our 
command. It acts by constricting the vessels of the inflamed area, 
and tends to prevent stasis and exudation. In many cases it seems 
to stop the inflammation before the tissues are broken down and 
actually to abort the inflammatory process. It should not be used in 
late stages of inflammation or in old and feeble patients. If continued 
too long actual harm may result through injury to the tissues. 

Da Costa insists that as cold prevents congestion, diminishes the 
activity of the leukocytes and lessens the protective reaction of the 
tissues, it should not be used in bacterial inflammation. From such 
a distinguished authority this statement carries a great deal of weight 
and is not to be disputed. However, there is considerable precedence 
for the use of the ice-cap in beginning appendicitis and occasion ally 
remarkably beneficial results will be seen when cold is applied to a 
superficial lymphangitis or a small area of local inflammation, such 
as a furuncle or sty. It has been suggested that cold acts in these 
cases through its action on the vessels, causing a limitation of the 
process of infection. In acute gonorrheal inflammation of the eyes, 
cold applications are the recognized form of treatment and give 
excellent results. In appendicitis it is, of course, impossible for an 
ice-cap applied externally to have an appreciable effect upon the 
tissues about the appendix. It is probable that the good results in 
such cases are due, in part, to counter-irritation and, in part, to reflex 
action upon the vessels. It is also possible, and in our opinion highly 
probable, that the bacteria in the tissue cells are more adversely 
affected by cold than are either the leukocytes or the tissue. Indeed, 
many of the remedies commonly used (quinine, arsenic, the roentgen 
ray, etc.) are injurious to the cells of the body, but they are more 



84 INFLAMMATION, SUPPURATION AND GANGRENE 

injurious to the causative agent of disease and thus tend to effect 
a cure. 

In the case of chronic inflammation or in the healing stage of acute 
inflammation there can be no argument. Cold rarely, if ever, shows 
a beneficial influence in such a case, and frequently its use is followed 
by actual harm. On the other hand, heat frequently exerts a favorable 
influence. 

Cold may be applied either wet or dry. Wet cold is less convenient 
to use than dry, and if long continued is likely to cause maceration 
of the skin. Plain ice-water may be used, or evaporating fluids, pure 
or diluted with water, may be applied. Thus, a mixture of half 
alcohol and half water is much colder than water alone. A mixture 
of lead, water and laudanum has been used extensively and is usually 
very grateful to the patient. Witch hazel, another time-tried remedy, 
probably acts chiefly as an evaporating lotion. In applying moist 
cold, wet compresses are wrung out of the solution and placed directly 
on the inflamed area. To get the best results they should be changed 
frequently. A piece of ice added to the solution increases its effect. 

Dry cold may be applied by the use of an ice-cap or an Esmarch 
coil. It is much more convenient than moist cold; it is more fre- 
quently used; it is said to be less likely to produce gangrene. To 
prevent injury to the skin when the ice-cap is used it should be sepa- 
rated from direct contact with the skin by the use of a thin piece of 
muslin or a handkerchief. Too long application of the ice-cap or the 
cold coil without this precaution will result in a local frost-bite of the 
skin— a so-called "ice-cap burn." 

In the use of the rubber coil ice-water is allowed to flow through a 
long strip of tubing which is coiled into a shape suitable for applica- 
tion to the part. The coil should always be separated from the skin 
by a thin layer of flannel or muslin. In addition, it is well in every 
case to make frequent inspections of the skin, removing the cold 
application if the appearance of the skin seems to indicate beginning 
frost-bite. 

Local Bleeding.— This is another method of treating inflammation. 
It includes puncture scarifications, the application of leeches, cupping, 
etc. 

Puncture not only causes the local abstraction of blood, but it also 
allows the escape of interstitial effusion, thus relieving tension and 
diminishing pain. It is usually used in the form of "multiple punc- 
tures," made either with a surgical needle or a sharp-pointed scalpel. 
The skin should be rendered surgically clean before the punctures 
are made, and a sterile dressing should be applied to absorb the exu- 
dation. The objection to puncture is that it is painful and may lead 
to the introduction of infection from without. 

Scarification consists in the use of large or small incisions in order 
to cause bleeding. This causes the relief of tension in the same manner 
as puncture, but the bleeding and exudation are induced to a greater 



INFLAMMATION 85 

degree. In some cases it may prevent gangrene when tissues are 
under great tension. It is commonly supposed to act as a counter- 
irritant. It is open to the same danger of infection as has been noted 
above. 

Cupping has been mentioned in speaking of hyperemia. When 
cups are used in conjunction with puncture or scarification they are 
termed "wet cups." The cup is applied after the incisions have 
been made, and the suction draws the blood into the cup. This has 
been used in the treatment of pleurisy and in muscular rheumatism. 

Leeches may be used to abstract blood locally. They leave a small 
scar and consequently should never be applied to the face. They 
should not be applied in the region of the eye where there is con- 
siderable loose cellular tissue, for they are likely to cause increased 
discoloration and swelling. The skin should be washed and shaved 
before the leech is applied. Application is conveniently made by 
placing the leech tail-downward in a test-tube and then inverting the 
tube over the skin. If the leech does not take hold at once, a drop of 
blood should be placed on the spot where the application is to be 
made. The leech should never be pulled off, but should be allowed to 
drop off when full. Occasionally, rather severe hemorrhage follows 
the application owing to an anticlotting principle excreted into the 
bite wound. 

Leeches are seldom used. They are not in keeping with the prin- 
ciples of modern surgery and there is rarely if ever an occasion where 
their use cannot be replaced by some other form of treatment. 

Counter-irritants act by their influence on the blood supply. They 
relieve pain and promote the absorption of exudate. In acute con- 
ditions they may serve to cause the withdrawal of the blood from the 
inflamed area and thus relieve pain. However, their value in acute 
inflammation is not always beneficial, and in some cases they seem to 
make the condition worse. Mustard, in the form of a plaster, is 
probably the commonest counter-irritant in general use. It may be 
used to cause vesication; or its action may be stopped at the stage 
of erythema. Other counter-irritants which may be used are can- 
tharides, oil of wintergreen, iodine, menthol, camphor, the actual 
cautery, etc. 

Tincture of iodine is a valuable counter-irritant. It should be 
painted on the part and allowed to dry without the application of a 
bandage. The painting may be repeated daily, but should be stopped 
when signs of vesication occur. In some cases iodine may result in 
a severe burn, and for this reason it is better to dilute it two or three 
times with alcohol. It is especially irritating to the delicate skin of 
children. Tincture of iodine should never be used with any combi- 
nation of mercury. A combination results in the formation of a 
highly irritating mercuric iodide which causes severe burns. Iodine 
is used in deep inflammations or surface inflammations of the chronic 
type. 



S6 INFLAMMATION, SUPPURATION AND GANGRENE 

Ichthyol in the form of an ointment, 20 to 50 per cent, is commonly 
used in the treatment of inflammation, both acute and chronic. It is 
generally supposed to have some specific influence upon inflammatory 
processes. Its actioD at present is not satisfactorily explained, but 
it is possible that it owes its valuable properties entirely to its anti- 
septic effect. It seems to act best when applied to inflammations of 
the skin, such as erysipelas, infective dermatitis, etc. 

Ichthyol has a very disagreeable odor, and for this reason many 
patients object to its use. Deodorized preparations have been 
marketed but are generally considered less efficacious than the un- 
altered substance. 

Guaiacol.—A 10 per cent solution of guaiacol in glycerin is a 
commonly used form of counter-irritation. It is absorbed by the 
lymphatics and exerts a systemic action which is commonly supposed 
to be of value in rheumatism and neuritis. Care should be taken not 
to use it in combination with iodine, as a severe burn may result. 

Heat— Either moist or dry heat may be applied for the relief of 
inflammation. Properly applied, heat is one of the best remedies 
that we have at our disposal. Applied directly to the inflamed 
part, heat causes dilatation of the vessels and increased blood supply. 
Applied at some distance, it acts as a counter-irritant. It is ordi- 
narily applied during the subacute stage after the acute symptoms 
have begun to subside. 

The use of the so-called " baking apparatus" supplies one of the 
best methods of applying dry heat. Ovens, large enough to contain 
an arm or leg, are carefully padded so that there is no danger of burn- 
ing and the heat is secured either from a gas burner or by electricity. 
If the skin is kept dry, patients are able to endure a high temperature 
in an apparatus of this sort. 

Electric lights have recently come into favor for the application 
of heat. For this purpose a cluster of the ordinary incandescent globes 
may be used or special fifty candle-power lights with metal reflectors 
may be secured from surgical supply houses. It is claimed that the 
radiant light assists the action of the heat as a curative process. 
This is not proved; but from a clinical standpoint radiant heat seems 
more efficacious than non-radiant. This form of heat is most active 
in cases of deep inflammation, such as synovitis of a joint or myositis 
following injury. It has little value on superficial inflammation of 
the infectious type. 

Moist heat may be applied in the form of the old-fashioned poultice, 
hot fomentations, or the hot bath applied either continuously or inter- 
mittently. 1 In the use of moist heat the body is not able to tolerate 
the high temperatures obtained in the use of dry heat. The action is 

1 A poultice is one of the oldest forms of applying heat and moisture, and is used in 
some form by civilized and savage races the world over. We make it a rule, with few 
exceptions, never to use poultices on suppurating processes until free drainage is estab- 
lished. Where the drainage is adequate and the process not too deep we know of no 
treatment as beneficial and as grateful to the patient as a large, moist poultice. 



INFECTED WOUNDS 87 

approximately the same whether moist or dry heat is used, the choice 
being dependent upon convenience and the desires of the patient. 
Occasionally a case will be seen which will improve rapidly under the 
use of dry heat after showing no improvement under the moist form 
of treatment; and at times the reverse is true. In obstinate cases 
it is well to try both plans. 

In any form of treatment involving the use of heat it must be 
remembered that we are dealing with an injured part in which the 
sensations may be benumbed, so the surgeon must not rely entirely 
on the word of the patient as to the degree of heat he can stand. The 
statement of the patient must be carefully checked by frequent 
inspections in order to prevent burns. 

INFECTED WOUNDS. 

Suppuration as a complication has been briefly referred to in the 
section on Wounds. We desire in this section to discuss the surgical 
aspect of infected wounds, especially in connection with more or less 
diffuse inflammation, to describe in detail the various methods of 
treatment, and to outline the indicated course of procedure for infected 
wounds in general. 

Symptoms. —The symptoms of infected wounds are those of the 
the original injury plus symptoms referable to the added inflamma- 
tion. They vary with the size and character of the wound, the type 
of the infection and the area of suppuration. In general, the symp- 
toms are more marked when there is any interference with the wound 
discharge, in which case there is usually acute tenderness and pain of 
a throbbing character. Fever and toxemia may be present and are 
apt to be more marked when there is retention of the discharge. They 
arise from the absorption of bacterial poisons and are, therefore, 
dependent upon the freedom of drainage and area of suppuration. 
They are naturally more marked in large wounds and in wounds in 
which the discharge is blocked mechanically. 

The type of infection influences the course of the disease and the 
character of the symptoms. Symptoms referable to the B. tetani are 
entirely different from those produced by the B. aerogenes capsulatus, 
and these again are unlike those produced by pus cocci. In speaking 
of suppurating wounds, infection with pus-forming bacteria is gener- 
ally understood. Specific infections, such as those mentioned above, 
are definitely referred to as such and not classed merely as infected 
wounds. However, the treatment for the prevention and cure of pus 
infections tends to prevent the development of unrecognized contam- 
ination with tetanus, anthrax and other similar forms of specific 
infection. 

Treatment.— The first essential in the treatment of an infected wound 
is to establish free drainage. Pus should never be confined under 
pressure. The wound should be thoroughly explored and deep suppu- 



88 INFLAMMATION, SUPPURATION AND GANGRENE 

ration, if present, should be provided with drainage by enlarging the 
wound or by the introduction of drainage tubes. If the wound has 
been sutured the stitches should be cut; and if blood clots or other 
material obstruct the outlet complete removal of the obstruction is 
in order. 

In addition, the general condition of the patient should receive 
attention. The vital forces should be conserved by rest, fresh air 
and a nourishing, easily digestible diet. If the discharge persists for 
a long time nutritive tonics, cod-liver oil and other similar remedies 
are of value because of their beneficial effect on the general health. 

Rest.— Practically all forms of treatment require rest of the infected 
wound during the period of healing. This is accomplished by the 
use of a splint or by rest in bed. The exception to this rule is the 
recently advocated treatment (Will ems) of infected joints by active 
motion which, it is claimed, will prevent adhesions and facilitate 
drainage. 

The physiologic treatment represents the attempt to assist the 
normal processes of Nature. The wounds are opened freely and 
irrigated more or less continuously with normal salt solution. This 
removes at once the products of suppuration and does not injure the 
new tissue. In the practical application of the treatment the wounds 
are dressed loosely with gauze placed over fenestrated rubber tubes 
which pass to the deepest part of the wound cavity and through 
which the stream of saline runs. In some cases the dressing is arranged 
so that the outflow is allowed to run into a basin or bucket. For 
practical purposes the solution may be made by adding a level tea- 
spoonful of salt to a pint of sterile water. The long-continued use 
of normal salt solution may lead to a mild degree of maceration of the 
cells, which become pale and washed out in appearance. This is of 
little consequence and disappears as soon as the irrigations are dis- 
continued. 

A hypertonic salt solution is used in the treatment of suppurating 
wounds in order to cause the active exudation of serum which in turn 
tends to wash out bacteria from the tissues and to increase phago- 
cytosis. It may be used in the form of a continuous irrigation or a 
wet dressing, or the wound may be packed with gauze saturated with 
a solution of 5 to 10 per cent sodium chloride. The efficiency of the 
above solutions may be enhanced by the addition of a small amount 
of sodium citrate (Wright's solution 1 ) which prevents coagulation of the 
exudate. Tablets containing about 10 grains of sodium chloride are 
placed in the folds of the gauze to increase the effect, and as they 
dissolve slowly the action is long continued. The gauze does not 
come beyond the level of the skin; and in deep wounds drainage is 

i Wright's solution: 

Sodium chloride 3 parts 

Sodium citrate 1 part 

Water 96 parts 



INFECTED WOUNDS 89 

increased by combining one or more rubber tube wick drains with 
the pack. A large dry dressing is applied over the pack and allowed 
to remain for twenty-four hours, when it will show a surprisingly 
large amount of seropurulent drainage from the wound. It is claimed 
that a better effect is obtained if the patient is required to drink a 
large quantity of fluid. 

Glycerin.— Closely related to the action of hypertonic salt solution 
is that of glycerin, which attracts water from the tissues and tends 
to soften crusts and prevent clogging Of the mouth of the wound. 
As glycerin is only slightly antiseptic, the attempt has been made 
to increase its efficiency by adding an antiseptic, such as iodine, boric 
acid, carbolic acid, etc. For out-patient practice we have for several 
years used the following solution: 

Tincture of iodine 10 parts 

Glycerin 90 parts 

This formula has a decidedly antiseptic effect, and at the same time 
it is only slightly irritating. It is easily prepared and keeps in- 
definitely. 

Open air and sunlight are becoming increasingly popular in the 
treatment of suppurating wounds w T hich have become sluggish in 
character and are not responding well to treatment. There is no 
doubt that wounds kept dry show less tendency to destruction of 
tissue than do wounds covered with a large quantity of pus-soaked 
gauze. 

The disadvantage of the treatment is that there is danger of con- 
tamination during movements in bed or from the dust of the air. 
We have found the following plan successful in a large series of cases: 
During the night and when the patient is up and around, the wound 
is covered w r ith an ordinary dressing. This is taken off daily and all 
loose crusts and scales are removed. The patient then sits with the 
wound exposed to the open air, or to sunlight if the day permits, for 
from one to three hours. The wound is then redressed and the same 
treatment repeated either on the afternoon of the same day or the 
following day. In some cases the wound may be covered with a cage 
which protects the wound and at the same time allows continuous 
exposure to the air and sunlight. 

In order to prevent the adhesion of gauze to the new granulation 
tissue, it has been found desirable to smear the wound with sterile 
ointment before applying the gauze; or better, to apply a latticework 
of rubber tissue directly to the wound before the application of the 
gauze. This will prevent the gauze from sticking and tends to soften 
large crusts and facilitate their removal. 

The use of sunlight whenever available is of extreme importance. 
Many large suppurating wounds will dry up rapidly when exposed 
to direct sunlight, after having failed to respond with more than a 
slight degree of improvement to open-air treatment without sunlight. 



90 INFLAMMATION, SUPPURATION AND GANGRENE 

In the absence of sunlight the ordinary incandescent lamp serves as 
an admirable substitute. The heat and light, confined by a hood 
which acts as a reflector, should be placed near enough to the wound 
to give a sense of warmth. The quartz mercury vapor light and 
the Finsen light have been used for the same purpose with excellent 
results. 

In the use of this form of treatment it is necessary not to confuse 
mere scabbing of the wound with dryness. When under the influence 
of sunlight or otherwise a healthy crust forms over the wound, it is, 
as a rule, unwise to remove the crust. If there is, however, a dry 
crust covering a small pool of pus, it should be removed at once. 

Antiseptics.— The antiseptic treatment of infected wounds is 
directed toward the destruction of bacteria which may have found 
entrance into the wound. Previous to the introduction of aseptic 
surgery, antiseptic treatment was practised almost exclusively. Just 
before the World War many surgeons had discarded antisepsis almost 
completely, depending entirely upon some modification of normal 
saline irrigation. The conclusion which led to this form of treatment 
was a result of the observation that most of the stronger antiseptics, 
such as carbolic acid and corrosive sublimate, caused a superficial 
destruction of the tissues and consequently delayed healing. 

The large number of suppurative wounds seen in war surgery has 
stimulated investigation into the possible value of antiseptics and 
has led to the wide adoption of the solution of H. D. Dakin, in which 
the active agent is chlorine. 

Dakin' s Solution.— If chlorinated lime and sodium bicarbonate are 
mixed together in the proper proportions a solution of sodium hypo- 
chlorite is obtained. This is unstable and deteriorates rapidly on 
standing. For use in infected wounds it should be prepared according 
to Daufresne's technic as follows: 

Chlorinated lime (bleaching powder) 200 Gm. 

Sodium carbonate (anhydrous) 100 Gm. 

Sodium bicarbonate 80 Gm. 

Place the chlorinated lime in a large 12-liter flask with 5 liters of ordinary clean water. 
Shake the solution vigorously for some time and then allow it to stand for from six to 
twelve hours. In another flask dissolve the sodium carbonate and sodium bicarbonate 
in 5 liters of cold water. The soda solution is poured upon the lime solution, shaken 
vigorously and allowed to stand. After thirty minutes the supernatant fluid is syphoned 
off, filtered through paper, and, if correctly made, is ready for use. If put in a dark- 
colored bottle, it will keep for ten days or slightly longer in a cool place. The bleaching 
powder must contain exactly 25 per cent of active chlorine or the resulting solution will 
not be the required strength, which should be between 0.45 per cent and 0.5 per cent, 
that is, a little less than half of 1 per cent. If it is weaker than this, the solution is too 
weak; and if it is stronger, it is irritating. 

Many of the negative results obtained with Dakin's solution were 
due to solutions improperly prepared. Unless the surgeon is willing 
to take the trouble to have the solution properly prepared by an 
expert chemist, he should use some of the simpler antiseptics and 



Infected wot/Nbs 



Si- 



leave the Carrel-Dakin treatment to hospital use. Some of the 
commercial preparations may be as good or better than Dakin's solu- 
tion, but this remains to be proved by clinical results. 

In order to test the solution for sodium hypochlorite, 10 cc of the 
solution should be carefully measured with a pipette and placed in 
a beaker with about 20 cc of distilled water. To this is added 2 gm. 
of potassium iodide, and with a burette a decinormal solution of 
sodium hyposulphite is slowly added until the solution is decolorized. 
The number of centimeters of hyposulphite required to decolorize 
10 cc of the solution multiplied by 0.03725, equals the percentage 
strength of sodium hypochlorite in the Dakin's solution. 




Fig. 36. — Simple method of using Dakin's solution. 



Carrel- Bahin Technic. —The most satisfactory form of using Dakin's 
solution is by what is known as the Carrel-Dakin technic. Here again 
the utmost attention to detail is required, and if the best results are 
to be obtained the technic must be painstakingly carried out without 
modification. 

The object is to irrigate the wound frequently and to keep the 
wound constantly full of the solution. When in contact with the 
wound the solution soon loses its strength, so that frequent irriga- 
tions are necessary. For practical purposes it has been found that 



92 INFLAMMATION, SUPPURATION AND GANGRENE 

if a wound is properly dressed and then irrigated every two hours, an 
almost constant action is obtained. 

For the Carrel-Dakin technic the following materials are necessary, 
in addition to properly prepared Dakin's solution. 1 

1. A glass irrigating jar, capacity 500 to 1000 cc. 

2. Two or three yards of rubber tubing. 

3. An adjustable clamp for control. 

4. Rubber installation tubes about the size of a No. 16 French catheter, tied at the 
ends and perforated with holes made with a punch. The diameter of these tubes varies 
from 4 mm. to 7 mm. and the diameter of the punch holes is 1 mm. 

5. Ordinary rubber-tube drains. 

6. Glass connecting-tubes. 

7. Dressings. 

The wound should be prepared, as for any other form of antiseptic 
treatment, by the careful removal of all foreign bodies and loose 
particles of bone and all tissues which are not likely to regain vitality. 
Bleeding should be stopped and all cavities thoroughly explored. 
Counter-openings are rarely required. In superficial wounds the 
tubes may be wrapped in Turkish toweling or gauze and placed on 
the wound. In deeper wounds the tube should reach to the bottom 
of the cavity so that the solution will fill the wound before being 
discharged. In wounds with a dependent opening the tube should 
pass through this opening to the upper part of the wound, the opening 
being partially plugged with gauze to cause retention of the solution. 
If the wounds are on the hand or foot the part may be placed in a 
basin of solution for from five to ten minutes at regular intervals. 

The tubes are left constantly in place, but the gauze should be 
changed daily. Irritation of the skin may be prevented by the use 
of vaseline. If the flow is carefully adjusted the wound will be amply 
bathed in solution and there will be little overflow. In practice it has 
been found necessary to apply the solution at intervals of two hours 
both night and day. It must be appreciated that the Carrel-Dakin 
treatment is of necessity an institutional form of treatment. Con- 
sequently its use is very limited in minor surgery. Occasionally, 
however, a patient will be found who is able to carry out the treat- 
ment at home with enough attention to detail to gain most beneficial 
results. In the ordinary out-patient practice our results with this 
form of treatment have been unsatisfactory. 

Systematic examination of the discharge is usually combined with the 
Carrel-Dakin technic, and consists in counting the number of microbes 
shown in a microscopic field of a thin smear made from the secretion. 
While this is open to some objections as to accuracy, it is nevertheless 
a guide to the general bacteriologic condition of the wound. During 
the first few days the fields will be seen swarming with bacteria, then 
they become less and, if the treatment has been successful, in from 
five to eight days the microscopic examination will be found negative 

1 Lyle: Jour. Am. Med. Assn., January 13, 1917. 



INFECTED WOUNDS 93 

for bacteria. Wounds found sterile 1 on three successive examinations 
may be closed by secondary suture. If the wound does not become 
bacteria-free there is either an error in technic or the wound contains 
a foreign body or a localized pocket of pus. This method may, of 
course, be used with any other form of wound treatment. 

Eusol is the name given to a solution consisting of 0.5 per cent solu- 
tion of eupad. Eupad is made by mixing 12.5 gm. of chlorinated 
lime with an equal quantity of powdered boric acid. Eusol was 
widely used in England during the war, with very favorable results. 
It is easily prepared, but is likely to show considerable variation in 
strength due to the variable chlorine content of the lime. If kept in 
dark bottles and in a cool place it retains its strength for a week or 
longer. Gauze impregnated with eupad is used for packing septic 
wounds. Moisture causes the slow liberation of the antiseptic, which 
acts in the same manner as the solution. 

Dichloramin-T is a more stable compound than either Dakin's 
solution or eusol. It is prepared synthetically from chlorinated lime 
and is much less irritating than the free chlorine solution. It comes 
in powdered or crystalline form and retains its strength for a long 
period if kept dry. It is used in surgery generally in the form of 
chlorinated oil, from which the chlorine is slowly liberated in the 
wound over a period of from eighteen to twenty-four hours. 

Da Costa recommends the following mixture: 

Dichloramin-T powder 156 grains 

Chlorinated paraffine oil 1 ounce 

Chlorinated eucalyptol 3 ounces 

making a 7.5 per cent solution. The oil may be introduced into the 
wound on gauze or by the use of a spray or syringe. It is recom- 
mended because it is cheap, convenient and applicable to out-patient 
practice. It is less efficient than the watery solution, because it does 
not destroy necrotic tissue. 

Flavine is a recently introduced antiseptic prepared synthetically 
from coal-tar. It will destroy bacteria without destroying cells, and 
does not seem to lose any of its antiseptic properties in the presence 
of serum. It is used in watery solutions in about the same strength 
as the mercuric salts, and is applied to wounds in the form of a wet 
dressing. Reports of its use in infected wounds have been very 
favorable. 

Carbolic acid in watery solutions is likely to cause gangrene. This 
may happen no matter how dilute the solution and is due to the 
fact that as the water evaporates the non- volatile carbolic acid remains 
in a concentrated state. For this reason, aside from the constitutional 
effects caused by the absorption of carbolic acid, its use as a wet 
dressing in septic wounds should be abandoned. If wounds are 

1 This refers to the examination of the smear. Cultures would probably show a few 
bacteria. 



94 INFLAMMATION, SUPPURATION AND GANGRENE 

irrigated with carbolic acid the excess of the solution should be washed 
away before they are dressed. 

Carbolic acid may be used in glycerin or as an ointment up to 
5 per cent with less danger of gangrene; but due to the fact that the 
odor of carbolic acid is easily recognized by patients and that many 
cases of gangrene of the fingers have resulted from so-called home 
treatment on the patient's own initiation, it is perhaps better for 
the surgeon to avoid the use of carbolic acid except in special cases. 
There are many other antiseptic wet dressings suitable for wounds 
which are just as efficient as carbolic solutions and much less dangerous. 

Bichloride of mercury (corrosive sublimate) is a time-honored anti- 
septic, and in test-tube experiments it is an effective germicide in 
strengths as weak as 1 in 5000. For wound dressings it may be used 
in strengths of 1 to 1000 to 1 to 5000. When combined with serum 
or some other form of albumen it forms an insoluble albuminate, 
and is thus rendered inert. It is not germicidal in the presence of 
oil, and it is irritating to the skin if used over a long period. It is 
very poisonous and should not be used on mucous membranes except 
in extremely dilute solutions, 1 to 5000 or weaker. It may be absorbed 
and cause poisonous symptoms and it is rather uncertain in its action 
on some bacteria. 

Bichloride of mercury may be used for the disinfection of glass- 
ware, rubber gloves, basins and other similar utensils, and for the 
patient's skin or the hands of the operator; but it should not be used 
in the direct treatment of either aseptic or infected wounds. 

Boric acid solutions are so mildly antiseptic that their use in irri- 
gations and wet dressings approaches the physiologic method of 
treatment. However, from a practical standpoint boric acid serves 
admirably for out-patient practice. It is cheap, easily obtained and 
convenient to apply. Moreover, it has appeared to us that during 
the acute stage in certain infected wounds the drainage obtained by 
means of a bandage kept soaking wet with a mild antiseptic solution 
was of much more value than the use of a much stronger antiseptic 
on a bandage which was dry, or nearly so. Patients may be given a 
supply of boric acid and instructed to mix one to two teaspoonfuls 
in a pint of ordinary water, and thus secure sufficient solution to keep 
the dressing wet at all times. The practical advantages of boric 
acid will be found in many cases to outweigh its disadvantages as an 
antiseptic. It may be used freely on mucous membranes without 
fear of irritation; and if absorbed in small quantities, it is not poisonous. 

Iodoform is another of the time-honored antiseptics used in the 
treatment of wounds. It acts through the liberation of iodine in 
wounds; and although only mildly antiseptic in test-tube experi- 
ments, it has a powerful action on the growth of bacteria in wounds. 
Experiments seem to show that its antiseptic powers are due in part 
to the irritating property of the drug which causes a local outpouring 
of leukocytes, Granulation tissue has been proved to have the power 



INFECTED WOUNDS 95 

of decomposing iodoform. Da Costa believes that it is of much more 
value in cavities than on free surfaces. It is generally used in the 
form of iodoform gauze, less frequently as a dusting powder. A 
favorite method of use in cases of tuberculous abscess is in the form 
of a suspension (2 to 4 per cent) in glycerin. 

Iodoform may be used in suppurating wounds, in abscess cavities, 
in foul-smelling ulcers and in bone sinuses. It is especially valuable 
in all cases of surgical tuberculosis. As the pure drug is not anti- 
septic in vitro, it should be sterilized by the use of formalin vapor 
before being used in wounds. 

Iodoform poisoning is not uncommon and consequently the drug 
must be used with some caution. The symptoms are sometimes 
acute and arise suddenly. Delirium, nausea, fever and an eruption 
on the skin resembling measles, are fairly common symptoms. The 
breath smells of iodoform and there is a metallic taste in the mouth. 
Examination of the urine shows the presence of iodoform. These 
symptoms may go on rapidly to coma and death. Local irritation 
of the skin is sometimes caused by the use of iodoform. It may be 
eczematous or vesicular in character. Whenever symptoms of 
poisoning, either local or general, occur the use of iodoform should be 
stopped at once. 

The danger of iodoform poisoning is a serious objection to the use 
of the drug. The danger is greater in childhood and old age and in 
persons suffering from debilitating disease, than it is in strong, healthy 
individuals. 

Aristol is an odorless iodine preparation and is used as an antiseptic 
dusting powder. It is less toxic than iodoform, but it is also much 
less powerful, and is only of value as a drying agent in a wound showing 
little or no discharge. 

Calomel, either used pure or mixed with talcum, is a valuable anti- 
septic powder. It is widely used in antisyphilitic treatment, and is 
of value in foul-smelling ulcers where a drying powder is desired. In 
certain types of deep inflammation, especially erysipelas, we have 
found the following ointment very beneficial. 

Calomel 1 part 

Lanolin 4 parts 

Petrolatum 5 parts 

Used over a large area and for a long period, enough calomel may 
be absorbed to cause salivation. 

Bipp is a paste made by mixing 1 part of bismuth subnitrate with 
2 parts of iodoform and enough petrolatum to make a thick paste of 
about the consistency of soft butter. It was developed for use in 
war surgery and in some cases gave very satisfactory results. It is 
used for suppurating wounds or for bone cavities, but it is not adapted 
to wounds surrounded by a wide area of cellulitis. After the wound 
is opened so as to expose freely all its recesses, it is mopped out with 



96 INFLAMMATION, SUPPURATION AND GANGRENE 

alcohol, dried and then filled with the paste, care being taken to reach 
every crevice. A dry gauze dressing is then applied over the paste. 
The dressing need not be changed for several days or a week; and 
when the dressing is changed it is only necessary to wipe the discharge 
from the wound with alcohol and reapply the paste. In some cases 
of compound fracture the dressing is not changed for two or three 
weeks, apparently without bad results. Iodoform poisoning may 
develop if too much is used; but is much less likely to occur than in 
the use of iodoform gauze. For simplicity and convenience the 
frequent instillations of hypochlorite solution cannot be compared 
with the use of Bipp. Whether it will prove as efficacious as the 
chlorine derivatives when more widely used in civilian surgery is not 
yet determined. 

In the choice of an antiseptic the surgeon must be guided by the 
character of the infection, the condition of the wound and the patient's 
general health. In acute inflammation wet dressings are superior to 
other methods of treatment. 

After a wound has reached the subacute or chronic stage a change 
may advantageously be made to an antiseptic, such as iodoform or 
iodine and glycerin. In the late stages some form of stimulating 
dressing may be applied, such as balsam of Peru, or an astringent 
drying powder, such as dermatol. 

Secondary Closure of Wounds.— The use of the Carrel-Dakin treat- 
ment of war wounds has demonstrated that wounds may be rendered 
practically sterile and closed by secondary suture, thus greatly decreas- 
ing the period of convalescence. After smears taken from the wound 
show less than one bacterium per microscopic field for three successive 
examinations, the wound is considered sterile and may be closed by 
careful layer sutures. This can be accomplaished in a favorable 
case between the fifth and the ninth day. If for any reason suturing 
is not practicable, adhesive strips laced together with rubber bands 
may be used to approximate the edges of the wound. Skin traction 
may be obtained by the use of two strips of canton flannel with ordi- 
nary dress hooks sewn along one edge. These strips are carefully 
sterilized and then glued firmly to the skin. By use of rubber bands 
or a long elastic lace, continuous traction may be applied, pulling 
the wound edges together. During secondary closure the most 
careful aseptic technic must be employed for wounds of this type 
are very easily reinfected. 

Cellulitis. — A certain degree of cellulitis is associated with every 
case of suppuration. It may extend only a fraction of an inch from 
the wound or it may spread rapidly and include the entire limb. 

In some cases a diffuse cellulitis occurs from an insignificant wound, 
such as a scratch or pin-prick, spreads rapidly and is associated with 
chills, fever, local swelling, pain and tenderness. The skin is a dusky 
red and likely to be indurated. The edge of the inflamed area is 
usually not clearly marked. In some cases longitudinal streaks 



INFECTED WOUNDS 97 

extend up along the lymphatics (lymphangitis). Severe cellulitis of 
this type is caused by infection with an especially virulent organism, 
usually a streptococcus, occasionally associated with bacteria of 
putrefaction. Diffuse, spreading cellulitis is more likely to occur 
after periods of exhaustion as seen in war injuries or in persons of 
poor general health. It is not rare after typhoid and other fevers. In 
surgeons and nurses it frequently follows small injuries received when 
operating, the cellulitis being often more severe in the surgeon who 
has cut his finger with an infected scalpel than in the patient undergoing 
operation. 

Diagnosis.— Diffuse cellulitis must be diagnosed from erysipelas, 
from phlebitis and from acute arthritis. Infection with the gas 
bacillus gives a peculiar gangrenous infiltration of the muscles asso- 
ciated with the formation of gas, which can be felt beneath the skin 
as a peculiar sensation of crepitus. Swelling of the part, fever, pros- 
tration and a history of infection make the diagnosis of diffuse cellu- 
litis comparatively simple. In cellulitis following large infected 
wounds or compound fracture the infection is likely to spread along 
tissue planes or along tendon sheaths. In diffuse, spreading cellulitis 
pockets of pus may form at a considerable distance from the original 
focus. In the most acute cases it is not unusual to find large areas 
infiltrated with small collections of pus without finding a distinct 
abscess cavity. 

Treatment.— In any case of cellulitis it is most important to dis- 
cover the primary focus of infection and to establish free drainage. 
In the case of a large wound this is easily accomplished by removing 
sutures, if any are present, and enlarging the opening of the wound, 
if necessary. In some cases counter-openings may be required. 

Where the infection has found entrance through a small scratch or 
abrasion, it is sometimes very difficult to determine the exact location 
of the primary focus. All scabs should be removed and every sus- 
picious point of entrance for infection should be incised to provide 
drainage. We know of no way to determine the presence of a small 
abscess except by the fact that there is almost always acute tender- 
ness at the point of infection. Recently a young man came under 
observation with swelling and edema of the entire forearm and all 
the other symptoms of a beginning cellulitis. There was no apparent 
wound of the forearm or hand, but the man remembered pricking his 
index finger with a pin a few days before. A careful examination of 
the finger showed a small puncture on the palmar surface of the proxi- 
mal phalanx. With the point of a lead pencil an area of acute tender- 
ness, not over 5 mm. in diameter, could be made out at this spot. 
This was incised and a minute abscess cavity opened. The hand 
and arm were wrapped in a large dressing kept wet continuously 
with boric acid solution. The swelling of the arm subsided in forty- 
eight hours. The incision of the finger healed in less than ten days. 

The question of incising an area of cellulitis is a most troublesome 
7 



98 INFLAMMATION, SUPPURATION AND GANGRENE 

one. There is no doubt that large incisions often do harm. On 
the other hand, when incisions are made at the right time they are 
followed by a rapid subsidence of the inflammation. Inasmuch as it 
is generally admitted that when frank pus is present incision is indi- 
cated, the question resolves itself into when pus may be found. Inci- 
sion should be advised when there is a localized abscess as evidenced 
by redness, tenderness and fluctuation; when there is an area of 
induration localized and suggesting the presence of a deep abscess; 
and when the entire part is so swollen and tense that there is evident 
danger of constriction and interference with the blood supply. In 
cases of diffuse "boardy" induration the value of incision is less 
clearly indicated; but as many of these cases show multiple sub- 
cutaneous abscesses, incision will frequently lead to subsidence of the 
inflammation. The point chosen for incision should be the point 
of greatest tenderness. There is no advantage in opening areas of 
simple edema which surround the inflamed area, nor is it good 
surgery to extend the incisions for a long distance into normal tissues; 
but the opening, wherever made, should be large enough to allow 
free evacuation of discharge from the infected region. Students 
frequently mistake the area of edema which occurs on the back of 
the hand in the early stages of infection of the palm for cellulitis. 
Such an error is to be avoided, as incision would be detrimental. 

Drainage is best secured by the use of soft rubber tubes. Gauze, 
unless it is kept constantly wet or covered with an oily preparation, 
soon becomes clogged with dried serum and blood and serves to plug 
the opening. Dry gauze used for a drain in an abscess cavity is ineffi- 
cient. If the gauze can be kept constantly wet it will continue to 
act as a track for the discharge, but even then less satisfactorily than 
rubber tubing. 

If the cellulitis is secondary to a large wound, one of the forms of 
treatment outlined under infected wounds should be instituted, 
preference being given to those forms of treatment which keep the 
wound constantly soaked in a watery solution; but if the cellulitis is 
of a diffuse, spreading type and out of all proportion to the size of the 
wound, treatment of the wound area alone will be insufficient and wet 
dressings must be applied to the entire area of inflammation. For 
this purpose Dakin's solution, because it irritates the skin, is not 
suitable. Salt solution, dilute mixtures of alcohol (10 to 50 per cent) 
and weak solutions of aluminum acetate have all given fairly satis- 
factory results. Boric acid in from 1 to 4 per cent solutions has been 
found the cheapest and most convenient solution for use in ambula- 
tory patients. It may be used either hot or cold, as the condition 
indicates. 

It has been asserted that boric acid is absorbed and has a certain 
antiseptic effect in the tissues. This is doubtful; but the effect of 
moisture upon inflamed tissues, even when obtained from the ordinary 
tap water, is of undisputed value. Whether it acts by causing dilata- 



INFECTED WOUNDS 



99 



tion of the vessels or through osmosis has not been decided. Acting 
on the osmotic theory, the use of concentrated solutions of magnesium 
sulphate has been advised. We have not found them superior to solu- 
tions made with boric acid. 

When the tissues become pale and washed out in appearance and 
the skin shows slight evidence of maceration, it is usually advisable 
to discontinue the use of the wet dressing and to use some other form 
of dressing, such as Bipp or iodine and glycerin. 

The healing stage of cellulitis differs in no way from the healing 
stage of an infected wound. 




Fig. 37. — Ulcerating gumma of the back. Patient also had epithelioma of cuter 
canthus of the eye and in the axilla. Diagnosed as inoperable. Yielded rapidly to silver 
arsphenamine and iodides with mercurial treatment locally. The epitheliomata were 
successfully treated with radium. 



Acute Abscess. — An abscess is a circumscribed collection of pus 
generally caused by infection with pathogenic bacteria. While there 
is no doubt that an acute, sterile abscess may occur experimentally 
after the injection of turpentine and some other chemical irritant, 
a bacterial abscess is practically the only type met with in clinical 
experience. Consequently every abscess should be considered as 
infectious and treated accordingly. 

Unless the pus is circumscribed, the condition cannot properly be 
called an abscess. Purulent infiltration and localized cellulitis may 
show pus on incision, but unless the condition is localized by a con- 
nective tissue wall it is not an abscess. Collections of pus in a natural 
cavity, such as the antrum or the pleura, are sometimes called abscesses. 
They differ from our ordinary conception of an abscess, because they 



100 INFLAMMATION, SUPPURATION AND GANGRENE 

occur in a natural cavity and are not surrounded entirely by a new- 
formed wall of inflammatory tissue. 

The infection may gain entrance directly, as though a puncture 
wound or an infected hair follicle, or it may be carried from a distant 
point by the lymphatics or blood streams. 

During the early stage of infiltration and stasis, the condition is 
practically a localized cellulitis. If the protective reaction of the 
body is able to wall off the infection, the central portion becomes 
liquefied and an abscess results. If, on the other hand, the reaction 
is insufficient either because of the virulence of the infection or the 
weakened powers of resistance, the process extends along the lines 
of least resistance and diffuse cellulitis results. As the abscess increases 
in size, the tissue from within outward liquefies, forming pus, and 
the surrounding inflammatory zone continually enlarges. An abscess 
may continue to increase in size until it ruptures externally or into 
a hollow viscus, or it may, but this is rare, become quiescent and 
remain stationary for a long period, finally increasing again in size 
either because of local irritation or diminished general resistance. 
In very rare instances small abscesses after becoming quiescent may 
disappear entirely through absorption. 

Symptoms. —The symptoms during the early stage of abscess forma- 
tion differ in no way from those of localized cellulitis. Later, when 
liquefaction occurs, the center of the area becomes soft and finally 
fluctuates. The pain of the abscess varies with the nature of the 
tissue involved. In dense, fibrous or bony tissue it may be intense; 
while in loose, cellular tissue, spontaneous pain may be slight or 
absent. There is usually redness of the overlying skin, but in a 
deep abscess this symptom may be entirely absent. Constitutional 
symptoms always accompany an abscess, but in small abscesses, and 
larger ones during the quiescent stage, the general symptoms may be 
so slight as to be overlooked. Fever, toxemia and leukocytosis are 
usually present during the acute stage. Diagnostic puncture with 
an aspirating needle may be resorted to for the determination of the 
presence or absence of liquid pus. 

Treatment.— In general, the treatment consists of incision and 
drainage. During the early stages the application of poultices and 
hot fomentations are advised for the purpose of aiding the processes 
of localization, but, as a rule, we have advised against the use of 
poultices until adequate drainage has been secured. The exception 
to this rule is seen in abscesses secondary to infections of the lymph 
nodes, when it is usually safe to wait until the abscess is definitely 
localized. 

It is claimed that abscesses heal more rapidly if they are allowed 
to become well localized before incision. Some operators carry this 
so far as to insist on fluctuation or the demonstration of pus by aspi- 
ration before operating, basing the practice on the fact that after 
the abscess becomes quiescent the contained bacteria are attenu- 



INFECTED WOUNDS 101 

ated in virulence and are not so likely to cause reinfection through 
the newly-opened tissues in the area of incision. This doctrine is 
fairly logical but it has one weak point. There is no way of knowing 
that the abscess is in process of becoming quiescent or even that the 
pus is becoming circumscribed. Delay of incision in an acute abscess 
places the patient in danger of spreading cellulitis, and this danger is 
much greater than that of the introduction of infection through the 
newly-made wound. 

Da Costa puts it briefly as follows: a In the treatment of abscess 
there is one absolute rule which knows no exception, namely: that 
whenever and wherever pus is found the abscess should be evacuated 
at once, and after evacuation, thorough drainage should be provided 
for. It should be opened up early if possible, even before fluctuation 
and positively before pointing, to prevent tissue destruction, sub- 
fascial burrowing and general contamination." The presence of pus 
does not necessarily imply a large or even a moderate-sized cavity. 
The focus at the center may be so small as to be almost imperceptible. 
If, in an area of cellulitis, the surgeon has reason to believe that at 
the center there is a point of infection, it is not necessary to wait for 
the entire central portion of the inflamed area to break down. Inci- 
sion should be made at once. 

In a superficial abscess the skin should be cleaned and shaved if 
necessary, and the entire operation performed under aseptic precau- 
tions as in operating upon a sterile wound. It is a serious error of 
judgment to omit the necessary aseptic preparations merely because 
the abscess is already infected. The superficial nerves and vessels 
should be located if possible and the incision planned to avoid them. 
In the face the scar will be less disfiguring if it falls in the natural 
lines; and on the fingers scars are less troublesome if they avoid the 
flexor surfaces over the joints. In superficial areas where there are 
no structures to be wounded, the incision may be made with a sharp- 
pointed bistoury, which is introduced, point first, into the cavity. 
The incision is then made from within the cavity outward. This 
method is valuable in cases where an anesthetic is undesirable and 
the incision must be made rapidly on account of pain. 

In deeper abscesses, especially those in the region of the axilla or 
neck, where large vessels and nerves may be injured, it is better to 
perform the operation under nitrous oxide anesthesia and to make 
the incision with a scalpel, recognizing and avoiding important struct- 
ures if they are encountered. In all cases the incision should be 
made, if possible, at a dependent portion of the cavity. 

In deep abscesses, where the pus cavity is at a considerable depth 
and complete exposure is consequently impossible, the following plan 
is adopted: After the skin and fascia are incised a grooved director 
is pushed down toward the abscess. When the pus is seen oozing 
along the groove it is certain that the cavity has been entered. A 
pair of closed scissors or an artery clamp is introduced along the 



102 INFLAMMATION, SUPPURATION AND GANGRENE 

director, forcibly opened, and withdrawn. This can be repeated if 
necessary. The director can be left in place to serve as a guide for 
the introduction of drainage. If the cavity is not too deep and if 
there is no danger of dividing important structures, one blade of a 
pair of blunt-pointed scissors may be introduced into the cavity, which 
is then opened throughout its entire extent so that adequate drainage 
may be secured. In some cases where this plan is impracticable it 
may suffice to make a counter-opening at the most dependent portion 
of the cavity. 

The surgeon should make certain that the abscess is thoroughly 
opened, but care should be taken not to break down the walls of 
the abscess cavity which serve as an effective barrier against the 
spread of the infection. In many cases the mistake is made of opening 
only the superficial portion of the cavity. This is frequently seen in 
the so-called collar-button abscess, in which an abscess situated at 
some depth may break through a small hole in the fascia and form 
a secondary cavity beneath the skin. This condition consists of a 
large abscess cavity beneath the fascia, a narrow neck and a small 
cavity superficial to the fascia, the whole roughly resembling the 
shape of an ordinary collar button. 

The abscess may be irrigated with warm saline or some form of 
mild antiseptic solution and drainage introduced. Rubber tubes, 
rubber tissue or gauze smeared with ointment, are the best drainage 
material. Dry gauze should not be used. 

The after-treatment is essentially the same as that of an infected 
wound. The antiseptic form of treatment has seemed to us to give the 
best results. Drainage should be continued until the cavity becomes 
sterile or until the discharge becomes scanty and serous in character. 



GANGRENE. 

By gangrene is meant the death of tissue in portions large enough 
to be plainly visible, in contradistinction to ulceration, in which the 
tissue is liquefied and discharged in small particles. Gangrene is 
distinguished from necrosis only in a clinical sense. Death of tissue 
en masse below the surface of the body is referred to as necrosis, while 
a similar condition which can be detected on the surface is called 
gangrene. 

Gangrene results from the cutting of the blood supply to the tissues 
over a period long enough to cause death of the cellular element. 
It is uncertain how long this cessation of circulation must endure 
in order to cause gangrene. In some cases a very short period is 
sufficient; in others the circulation may apparently be completely 
shut off for several hours without injury. Laboratory experiments, 
which show that tissue cells live for a long time under favorable 
conditions, would indicate that in addition to the local anemia there 



GANGRENE 103 

must be another active element in the production of most cases of 
gangrene. 

The blood supply may be interfered with by pressure, by embolism 
and by disease or injury of the vessel wall from without. Mechanical 
pressure interferes with the capillary flow and may cause gangrene 
when applied directly to the part for too long a space of time; or it 
may cause gangrene through stoppage of the arterial supply by pres- 
sure some distance away. The pressure may arise from without the 
body, as by constriction with a tight bandage, or from within by a 
new growth or inflammatory swelling. The death of the tissue may 
be caused by direct influences, such as heat, cold, chemical agents, 
bacterial toxins, trauma, etc. Predisposing causes of gangrene are 
seen in those general conditions associated with a state of poor nutri- 
tion, such as diabetes, starvation, prolonged exhaustion, exposure 
to cold and malnutrition following infections. Local disease of the 
arteries or nerves acts as a predisposing cause. In most cases two or 
more factors are at work. Thus, the patient with diabetes gets 
along perfectly well until there is an injury to the foot, which, instead 
of healing, results in gangrene; or a man with a wound of the brachial 
artery is apparently recovering until infection sets in and is followed 
by gangrene of the forearm. In soldiers exposed to severe cold, 
gangrene due to freezing of the fingers or ears is more frequent in 
those who are ill-nourished either because of lack of food or because 
of recent illness. 

Gangrene is clinically divided into the dry and moist variety. 
Either variety may be associated with infection, the character of the 
gangrene depending upon whether the tissues are dry or moist when 
the process begins. When it is secondary to infection the tissues are 
always swollen and edematous before the gangrene begins. Conse- 
quently, the infectious variety is always moist; while gangrene not 
of infectious origin may be either dry or moist. 

Symptoms. —The earliest symptom is paleness or cyanosis of the 
skin, which later becomes cold and anesthetic. After a few hours or 
longer it becomes livid and mottled purple or greenish in color. In 
the moist variety blebs are formed which contain a reddish or 
brownish fluid with a foul odor. There is usually considerable swelling 
and there may be severe pain at the point of obstruction, but there 
is no pain in the gangrenous area. The line of demarcation soon forms, 
there is an extremely foul odor and there may be fever and other 
evidences of septic absorption. In dry gangrene, such as follows 
embolism or thrombosis, the skin at first is cold, blanched and slowly 
changing to greenish or greenish-black. Later the skin becomes dry 
and leathery and finally, owing to evaporation, hard and horny. There 
is a distinct line of demarcation and at this point the tissues are moist. 
The line of demarcation may be very irregular, the point of occurrence 
depending upon the collateral circulation. Thus, in gangrene of the 
leg, due to obstruction of the femoral artery, the line of demarcation 



104 INFLAMMATION, SUPPURATION AND GANGRENE 

may be much higher anteriorly than posteriorly ; or gangrene may be 
very extensive in the skin and less so in the deeper parts, as is seen 
following burns and frost-bite. Large areas of skin may become 
gangrenous without death of the bone or deeper tissues. 

Treatment.— When, because of injury or blocking of a healthy 
artery, we have reason to fear occurrence of gangrene, the patient 
should be placed in bed with the extremity elevated. External warmth 
should be applied by hot-water bottles or other means, and the arm 




Fig. 38. — Brawny edema of extremity following extensive resection of axillary tissues 
including axillary vein and artery for carcinoma of breast two years before hand becoming 
gangrenous. 

or leg should be loosely wrapped in cotton. Care should be taken 
not to allow the bandage or clothing to cause constriction. In a 
few cases efforts may be directed toward the relief of obstruction, 
and this is especially so where the obstruction is due to pressure 
exerted by an inflammatory exudate. Often the opening of an abscess 
will relieve pressure which has threatened to cause gangrene of an 
entire limb. In other cases a fractured or dislocated bone may inter- 
fere with circulation and require reduction. If, in spite of these 



GANGRENE 



105 



precautions, gangrene supervenes, it is advisable in most cases to 
wait for a line of demarcation and then to amputate above it. An 
antiseptic dry dressing should be used while waiting to operate. 
In microbic gangrene, where the condition is spreading rapidly, it 
may be necessary to amputate at once. In gangrene of the surface, 
such as is seen following burns or frost-bite, apply a dry antiseptic 
dressing and wait for separation. If secondary inflammation occurs 
treat the condition exactly as a suppurating wound. In surface cases, 
such as follow erysipelas and some other infections, incisions are 
made to relieve the tension and hot, wet antiseptic dressings are 
applied. 

Senile Gangrene. — Senile gangrene is due to arteriosclerosis of the 
peripheral vessels and is more likely to occur in patients suffering 
from nephritis, diabetes, syphilis or lead poisoning. The exciting 




Fig. 39. — Spontaneous appearance of redness and pain over area of shoulder. No 
swelling, no constitutional symptoms. Later became dusky, then black line of demarca- 
tion formed and slough separated and rapidly healed. No anthrax or other organism 
found. 



cause may be thrombosis or a mild infection from a slight abrasion 
of the foot or an ingrowing toenail. There is a history of pain and 
numbness and a sensation of cold in the feet over a long period. The 
disease may progress rapidly and involve the entire extremity, or a 
small portion of skin or a toe may be thrown off and healing occur. 
As a rule, however, in old persons gangrene is likely to be more or less 
progressive. A line of demarcation will form and then after a few days 
or a week the tissue above will die and a new line be attempted. 

Treatment.— The treatment of senile gangrene is in the main preven- 
tive. The patient should be instructed to avoid any injury to the feet 
and especially not to attempt to cut corns or hangnails with unsterile 
instruments. Any injury to the foot requires rest and proper surgical 
treatment. The general condition should receive proper care and the 
patient should be warned to keep the feet warm at all times. Ringer's 



106 INFLAMMATION, SUPPURATION AND GANGRENE 

solution, given intravenously or by hypodermoclysis, has been recom- 
mended for the relief of threatened gangrene of this type. It should 
be given daily for ten to fifteen days. It acts apparently by reducing 
the viscosity of the blood. 

Raynaud's Disease. — Raynaud's disease is sometimes associated 
with symmetrical gangrene of the fingers or toes. It differs from other 
forms of gangrene in that there is no demonstrable organic change in 
the vessels or tissues. It is probably dependent on a nerve lesion which 
causes vasomotor spasm. This produces local anemia and in time 
leads to dry gangrene. There is often severe pain of a neuralgic 
character. 

Treatment.— The treatment when gangrene occurs, is conservative. 
The gangrenous areas are dressed with dry antiseptic dressings and 
allowed to separate spontaneously. 

Diabetic Gangrene. — Diabetic gangrene occurs most frequently in 
elderly persons. In many cases it is probably due to senile changes in 
the vessels as well as to sugar in the blood. It is usually brought on 
by a slight infection, such as follows a hangnail or an abrasion of the 
foot. The treatment consists of removing the underlying cause and 
the most painstaking care of apparently slight infections occurring in 
diabetics. If gangrene is limited to the toes it should be dressed with 
dry antiseptics, such as boric acid or iodoform; but if the foot is 
extensively involved, amputation should be performed at once. Most 
surgeons advise high amputation. The diabetes should receive 
appropriate treatment, but the presence of sugar in the urine should 
not be considered a contraindication to operation in cases of spreading 
gangrene. 

Gangrene from Ergot Poisoning. — Gangrene from ergot poisoning 
should be treated conservatively. As it is due to a constriction of the 

vessels, attempts may be made to dilate 
them by warm applications. The elim- 
ination of ergot may be hastened by 
purgation and diuresis. When the line 
of demarcation has formed amputation 
may be performed just above it, or 
the gangrenous areas may be dressed 
dry and allowed to separate sponta- 
neously. 

Phenol Gangrene. — Phenol gangrene 

Fig. 40. — Gangrene following results from the USC of phenol solutions 

application for twenty-four hours app lied to the extremities. Solutions 

by patient s mother of carbolic acid -i r. 

dressing. (Ashhurst.) as weak as 0.5 per cent, when ap- 

plied in the form of a wet dressing, 
have caused this form of gangrene. This is possibly because the water 
in the dressing evaporates faster than the phenol, so that after a time 
the solution is considerably stronger than when first applied. Phenol 
solutions should never be used for continued applications. Used in 




GANGRENE 107 

the form of an ointment phenol is less dangerous, but it may cause 
gangrene. The treatment is conservative. Alcohol, applied locally, 
is advised when gangrene occurs, but it is of doubtful value at this 
stage. Amputation is practically never required. The dead tissue 
separates and the area heals by granulation. 

Bed-sore or Decubital Gangrene. — Bed-sore or decubital gangrene 
is an example of gangrene caused by anemia due to continued pressure. 
It is favored by malnutrition and senile changes. Bed-sores are most 
common on the back over the sacrum, but they may occur at any other 
spot where there is long-continued pressure, as on the heel, elbow, 
buttock, etc. While they are most frequently seen in patients confined 
to bed, they may be seen occasionally in patients up and about, in 
which case the sore may be due to mechanical pressure by a splint or 
plaster bandage upon a bony prominence. 

In the early stages of bed-sore, the area is reddish and slightly 
mottled in appearance. Pressure with the finger blanches the skin 
but the color returns very slowly. Later, the skin becomes slightly 
edematous. If the pressure is relieved at this stage, the skin slowly 
returns to normal; but if the pressure is continued the color becomes 
purplish or black and the skin slowly separates, leaving an ugly, deep, 
foul-smelling ulcer. 

Bed-sores are most common in parts that have been paralyzed or in 
patients so sick that their sensibilities are dulled. It is possible that 
slight trauma, such as that caused by the irritation of crumbs in the 
bed or a wrinkle or irregularity in the sheet, may aid in the formation 
of the sore. A mild infection of a slight scratch or abrasion can 
apparently act as an exciting cause in cases predisposed to this 
condition. 

Treatment.— The treatment should be directed toward prevention. 
Every patient confined to bed should receive constant attention to 
prevent bed-sores. This care should be increased in the aged and in 
those unconscious or seriously ill. If there is paralysis, either sensory 
or motor, the paralyzed part must be watched almost continuously. 
The patient's position must be changed at intervals, the bed linen must 
be kept clean and smooth, and an air-cushion or ring-shaped cotton 
support used to protect certain parts from undue pressure. The skin 
should be kept dry and clean, and hardened by massage and an alcohol 
rub. When the skin becomes reddened and it is feared that a sore is 
threatened, all pressure should be taken from the threatened area 
either by changing the position of the patient or by the use of a ring- 
shaped cushion. The skin may be washed two or three times daily 
with spirits of camphor. When there is an abrasion, it should be 
painted with iodine. If the skin actually breaks and there are signs 
of infection, the area should be dressed antiseptically with iodine and 
glycerin, or an antiseptic ointment, such as Bipp. A wet dressing 
of formalin, 0.5 per cent, is of value. Continuous wet dressings, because 
they cause maceration of the skin, are not advisable in the early stages 



108 



INFLAMMATION, SUPPURATION AND GANGRENE 



of bed-sores. In the later stages, the large ulcer may be dusted with 
iodoform or dressed with a wet antiseptic dressing, such as boric acid 
or Dakin's solution. After the slough has entirely separated and 
healing has commenced, balsam of Peru is often of value. Sunlight 
for two or three hours daily will often produce remarkable results 
during the healing stage. 

Noma. — Noma is the name given to a rapidly spreading gangrene 
occurring in debilitated patients recovering from an acute infectious 
disease. It is very rare and occurs most frequently in children. The 
bacteriology of the condition is not clear. It is thought by some to be 
due to pus organisms of especially high virulence. While it is seen 
most frequently in ill-fed and poorly-cared-for children, it may occur 

under excellent hygienic surroundings. 
It is most often located about the lip and 
cheek, less commonly about the ears, 
vulva and rectum. The disease begins 
as a small ulcer and spreads rapidly. It 
is most destructive and associated with 
a high mortality. 

Treatment.— The treatment consists of 
complete destruction of the gangrenous 
area with a cautery heated to a dull red. 
This should be done under general anes- 
thesia, using chloroform where there is 
danger of igniting the ether fumes with 
the cautery. After cauterization, anti- 
septic treatment should be rigorously 
carried out. 

Gas Gangrene. — Gas gangrene has al- 
ready been referred to in the discussion 
of infected wounds. It is very rare in 
civil life, occurring after crushing acci- 
dents when street dirt has been ground 
into the leg. Until the recent war when 
there was a large number of cases with a very high mortality, many 
surgeons had never seen a case. During the Civil War it is said 
to have been very rare. It is usually caused by the Bacillus aero- 
genes capsulatus, although generally this organism is found with 
others. It may occur alone or it may be impossible to demon- 
strate its presence. In a small per cent of cases the bacillus of 
malignant edema was the cause. The soil of the W T estern front was 
fairly teeming with microorganisms from both animal and human 
feces. The men in the trenches were covered with dust and dirt, and 
when wounded frequently lay in the mud for hours before receiving 
attention. Is it any wonder then that all sorts of infections w^ere 
prevalent? While figures are not yet available it would seem that gas 
infection w T as more common in the northern part of the line than at the 





^^ 


W ■"* CW *A 1 


^*B^|^ 


■ Jh 


l! 


^B Hit 





Fig. 41. — Noma (cancrum 
oris) of five days' duration in 
child, aged five years. No cause 
found. Culture showed only 
streptococci and staphylococci. 



GANGRENE 109 

southern end. In some advanced American hospitals, possibly because 
of the absence of infection, the technic of early treatment, or, more 
probably, because of the comparative inactivity of the sector, severe 
cases of gas infection were of extreme rarity. On the other hand, when 
there was a drive and many wounded were brought in, there was 
consequent delay in treatment, and the proportionate number of 
cases of gas gangrene was greatly increased. 

Laceration of the muscles, delay in treatment, compound fractures, 
and the presence of foreign bodies, especially particles of dirty clothing, 
all favor the development of gas infection. 

Symptoms.— The signs of infection are usually present from six to 
thirty-six hours after injury. The diagnostic symptoms are a peculiar 
gas crepitus when the tissues are pressed and the discharge of gas from 
the wound. In the early stages, the roentgen ray may show evidence 
of gas before it is evident to the touch. The infection spreads along 
the muscles and is more or less limited by muscle-sheaths and fascial 
planes. There is often a discharge of bubbles from the wound and the 
sensation of gas crepitation may extend for a considerable distance. 
There is marked swelling and edema; the skin may be dark red or pur- 
plish in color; and the wound discharge is usually brownish in color. 
There is an associated high fever and other symptoms of a severe 
toxemia. Death, in untreated cases, results within a few days to a 
week, or slightly longer. There is practically no tendency to a spon- 
taneous cure, although in the face, possibly owing to the excellent blood 
supply, fatal gas gangrene is said to be extremely rare. 1 

Treatment.— Preventive treatment consists of the exploration of 
every wound, the removal of all foreign bodies and dead tissue, the 
opening of all pockets, and the establishment of efficient drainage, 
combined with the use of Dakin's solution or other form of antiseptic 
treatment. This will prevent the development of gas gangrene even 
when the bacillus is known to be present. 

When the disease has actually begun, the wound should be widely 
opened and every muscle bundle which does not respond to external 
stimulus should be thoroughly removed. If this is carefully carried 
out and the Carrel-Dakin technic instituted, most of the cases will 
progress favorably. In later cases amputation must be performed, the 
flaps being left wide open to be sutured at a later date. The Bacillus 
aerogenes capsulatus, like the tetanus bacillus, will not develop in the 
presence of oxygen and, consequently, every effort should be made to 
leave the wound fully exposed to the air. Secondary closure should 
not be attempted until repeated examinations show the wound to be 
sterile. 

1 A colon bacillus mixed infection will sometimes show a small amount of gas with a 
foul odor, but the tissue crepitation is never present. Clotted blood in the tissues will 
give a sense of false crepitation which may be mistaken for gas infection. 



CHAPTER V. 
INJURIES TO THE HEAD. 

ABRASION OF THE FACE AND SCALP. 

Abrasions of the face and scalp are of importance because a dis- 
figuring scar on an exposed surface is a handicap in most walks of life. 
Abrasions of the head and hands are often associated with the introduc- 
tion of particles of sand or dirt which become firmly embedded in the 
abraded area, and which, unless removed, result in permanent dis- 
coloration of the skin. 

If the embedded material cannot be removed by simple washing, 
the abraded area should be well scrubbed with a stiff brush until all 
particles of dirt have been removed. If the abrasion is extensive, it is 
better to carry out this procedure under general anesthesia. 

After the wound is clean, it is sponged dry and painted with weak 
tincture of iodine, which is allowed to dry before the dressing is applied. 
In many cases there is only slight oozing which dries upon the surface, 
forming a protective covering which requires no further dressing. 

In small abrasions of the scalp, the application of iodine is usually 
the only treatment required. Bandaging the head is often unsatis- 
factory, the movement of the dressing serving to introduce infective 
material from the adjacent areas onto the surface of the wound. In 
addition, the removal of adherent gauze reopens the channel of infection 
and prevents healing. 

Should an abrasion upon the face or scalp become infected, the crusts 
must be removed and a dressing applied which will allow the discharge 
to escape. This may be accomplished either by a continuous wet 
dressing or by a weak antiseptic ointment, which prevents the adher- 
ence of the dressing and the formation of crusts. 

CONTUSIONS OF THE SCALP. 

Every case of contusion of the scalp should be viewed as a possible 
fracture of the skull. The more extensive the contusion and the more 
severe the injury, the greater is the probability of fracture. Cases 
showing few symptoms, following what was apparently only a com- 
paratively slight injury, may be associated with a depressed fracture of 
the skull. Contusion is followed in a few minutes by an effusion of 
serum and blood into the scalp, resulting in a well-defined rounded 
protuberance which is acutely tender on pressure. The swelling may 
disappear after a few days or it may persist as a hematoma. 



HEMATOMA OF THE SCALP 111 

Treatment.— The treatment of a simple contusion consists in the 
application of cold compresses or an ice-cap for the relief of pain and 
rest in bed in a darkened room until the symptoms of the associated 
concussion (headache, dizziness, etc.) have disappeared. It is well in 
all doubtful cases to keep the patient under observation for several 
hours or longer, in order to exclude the possibility of intracranial 
injury. While cases have been reported in which cerebral symptoms 
appeared after an interval of several days, the usual quiescent period 
is seldom longer than a few hours. The cases of neglected fracture of 
the skull, which frequently occur and often lead to legal complications, 
are seen in those patients who apply for treatment immediately after 
the injury showing absolutely no symptoms of intracranial injury, 




Fig. 42. — Contusion of the scalp. , Operation, recovery. 

and who on being dismissed from the hospital develop severe symptoms 
after a period varying between a few minutes and four or five hours. 
In hospital and dispensary practice, the rule should be made to keep 
all severe head injuries under observations for at least six hours after 
the accident. 

HEMATOMA OF THE SCALP. 

Hematoma of the scalp is a circumscribed collection of blood beneath 
the scalp usually caused by a blow. It may occur between the skin 
and the aponeurosis, beneath the aponeurosis, or between the perios- 
teum and the bone. When beneath the periosteum it is likely to take 
on the outline of the bone involved; otherwise it is usually circular in 
outline and raised somewhat above the surrounding surface. It is 



112 



INJURIES TO THE HEAD 



attached to the deeper parts, the skin being freely movable over the 
area of swelling. 

The blood may be gradually absorbed after a period of weeks or 
months. Rarely the mass becomes organized and a permanent 
fibrous tumor results. Suppuration is an occasional complication. 

A condition occurs during the process of absorption which is hard 
to differentiate from fracture of the skull. At one period the center 
of the hematoma becomes softened, while the edge can be distinctly 
felt as a hard rim around the central softened area. The sensation 
to the examining finger is that of a depressed fracture of the vault, the 
hard edge of the hematoma representing the sharp rim of the skull 




Fig. 43.— Osteomyelitis of occiput. Result of small infected hematoma. No external 

lesion. Duration, four weeks. 

about the apparent area of the depression. This condition should be 
borne in mind in all examinations for fracture of the vault. 

Treatment.— The treatment for persistent hematoma is either 
aspiration of the fluid contents or incision with expression of the 
contained clots. During the early stages it should be treated as a 
contusion and bandaged tightly to control the hemorrhage. 

Aspiration is only possible when the contents are fluid and, even in 
these cases, the aspirating needle is likely to become clogged with small 
clots which make the completion of the procedure difficult or impossible. 
Incision is usually more satisfactory. The scalp is shaved over an 
area about the size of a half-dollar and prepared for operation. An 
incision about three-eighths of an inch is made close to the margin of 



HEMATOMA OF THE SCALP 



113 




the hematoma, the point of the knife being directed into the cavity. 
The points of a pair of scissors are inserted into the wound, in such a 
manner as to cause the wound to gape widely. Pressure over the 
prominence of the hematoma will cause the clots and fluid blood to be 
expressed, after which the attached clots are removed from the inner 
surface with a gauze swab dipped in alcohol or 5 per cent carbolic acid. 
The alcohol or carbolic acid serves a double purpose; it acts as an 
antiseptic and as a local irritant, thus promoting absorption. After 
the cavity is well cleaned, the wound is sutured without drainage and a 
tight bandage is applied to prevent further exudation and to cause 
adhesion between the inner surfaces of the hematoma. 

Should infection occur either be- 
fore or after operation, incision and 
adequate drainage are indicated. 

Operation is usually most suc- 
cessfully performed about the third 
or fourth day after the formation 
of the hematoma. By this time 
bleeding will have ceased. Aspi- 
ration may be successful if applied 
very early before the blood has had 
time to clot. After clotting, aspi- 
ration will not be successful until 
the clot has again become liquefied, 
which is usually about the tenth 
day. 

Hematoma in the New-born 
(Cephalhematoma), is a rather fre- 
quent complication of instrumental 
delivery and is usually subperi- 
osteal in location. Because it 
follows the application of the ob- 
stetrical forceps, it is usually found in the parietal region on one or 
both sides. 

Hematoma must be differentiated from the edema of the scalp 
(caput succedaneum) occurring so frequently after labor. The latter 
disappears after the first few days; while the former remains the same 
size for a long period, or may even increase in size during the first few 
days. 

As the periosteum continues to form bone even when raised from the 
underlying cranium, and as suppuration and meningitis are not 
infrequent, early incision and drainage are indicated. 

Certain obstetricians advise against operation, on the ground that 
infection is more likely to occur after incision. Inasmuch as infection 
is likely to occur even without incision and as the external evidences of 
suppuration, such as pain and redness, are likely to be very slight in 
an infected hematoma thereby making the diagnosis of infection very 



Fig. 44. — Hematoma of scalp. 



114 



INJURIES TO THE HEAD 



difficult, it would appear that better results might be obtained by 
incision on the fourth or fifth day with expression of the clotted blood. 
A case recently seen demonstrates the dangers of the conservative 
plan of treatment. A full-term, nine-pound, healthy baby was delivered 
instrumentally after prolonged labor. After a few days, the sub- 
sistence of edema of the scalp showed a right parietal cephalhematoma. 
This was treated conservatively and became softer after the fifth or 
sixth day, but never showed the signs commonly associated with 
infection. On the ninth day, fever and convulsions developed and 
aspiration of the hematoma showed thin, sanguineous pus. Two days 
later the child died of septic meningitis. 

CONTUSIONS OF THE FACE. 

These are of importance because the associated ecchymosis is dis- 
figuring. During the period of exudation, cold compresses and local 
pressure limit the swelling and ecchymosis. After twenty-four hours 
gentle massage and warm applications will promote absorption. 




Fig. 45. — Swelling of lip, following a blow. 

Contusion of the Eye. — The familiar "black eye" is a result of con- 
tusion, the ecchymosis being particularly marked in the loose tissues 
about the eye. The application of cold, together with the later 
application of heat and light massage as described above, tends to limit 
the swelling and to hasten absorption. If the disfigurement is objec- 
tionable, the discoloration may be disguised by the use of ordinary 
theatrical grease-paint. After the paint is applied, a little powder 
serves to soften the shiny appearance. 

Subconjunctival ecchymosis is often a complication of contusion 
of the eye. It is due to a rupture of a small vessel beneath the con- 
junctiva and most often follows a blow, but it may be caused by violent 
respiratory movements, such as coughing and sneezing. Because the 



CONTUSIONS OF THE FACE 115 

blood is freely supplied with oxygen and is clearly seen through the 
transparent conjunctiva, it always remains bright red in appearance. 

Treatment.— The treatment is similar to contusion elsewhere, but 
is likely to have little or no influence upon the disappearance of the 
extravasated blood. Spontaneous recovery is the rule, the blood 
disappearing completely in about two weeks. 

Severe injuries to the eye demand the early attention of a specialist 
as they may result in intra-ocular hemorrhage, dislocation of the lens, 
and other injuries to the internal eye, causing blindness. 

Contusion of the Ear. — As a result of blows upon the external ear, 
hemorrhage often occurs beneath the perichondrium resulting in a 
hematoma of the ear which may vary in extent from a small tumor to 
one occupying the entire surface of the ear (boxer's ear) . The absorp- 
tion of the contained blood in these hematomata is extremely slow. 
Indeed, the rule appears to be organization of the clot rather than its 
absorption. If seen early, pressure applied to the surface of the ear 
may limit the extension of the hematoma. Later, incision is indicated 
with removal of the clots, and a tight bandage so applied as to hold the 
perichondrium in contact with the cartilage. Drainage is usually not 
advisable. 

In some cases blows upon the ear may cause rupture of the ear drum. 
This is diagnosed by hemorrhage from the meatus and by direct inspec- 
tion. No special treatment is necessary, except ordinary surgical 
cleanliness. 

Contusion of the Nose. — This condition requires no special treat- 
ment unless accompanied by hemorrhage from the nasal cavity 
(epistaxis) . It may be associated with fracture of the nasal bones, or 
injury to the delicate structures in the nasal cavity. 

Hemorrhage from the nose is a frequent complication of contusion 
of the nose and of fracture of the nasal bones. In some cases it is due 
to direct injury to the lining membrane caused by forceful blowing or 
lacerations made with the fingernail or a sharp instrument. Occa- 
sionally it occurs without apparent cause, especially in persons having 
high blood-pressure and in certain cases of vicarious menstruation. 

Treatment.— In most cases the hemorrhage tends to stop of itself 
after a few minutes. If the patient will hold the head up and avoid 
attempting to clear the nostrils by sniffing or blowing, a clot will soon 
form which ordinarily stops the hemorrhage. Patients usually cause 
the bleeding to persist by holding the head over a basin and blowing the 
clots out as soon as they form. Many patients will say they cannot 
hold the head up because the blood passes backward into the throat. 
This can cause no harm, the blood being easily expectorated into a cup 
or basin without lowering the head. Another simple method which 
will stop many cases consists in holding the nostrils firmly closed with 
the thumb and finger while the patient sits with his head bent well 
forward between his knees. This causes the nostril to fill with blood, 
which clots, stopping the bleeding. 



116 INJURIES TO THE HEAD 

Various other procedures are recommended as aids in stopping 
epistaxis. A cold object placed upon the back of the neck, cold water 
snuffed up into the nose, and the raising of both arms above the head, 
all have some influence. A method, which has been found unusually 
efficacious in obstinate cases, is the introduction of a small mass of 
finely crushed ice into the nostril from which the hemorrhage comes. 
A small piece of ice is crushed in a towel until it takes on the character 
of coarse snow. It is then molded with the fingers into a small cylindri- 
cal-shaped mass, about the size of a suppository, and inserted into the 
nostril. This is sufficient to stop fairly obstinate bleeding. 

In some cases the hemorrhage is quite severe ; at times it may be even 
so persistent as to endanger the patient's life. In such cases the cavity 
of the nose should be inspected and the location of the bleeding point 
noted. Usually this point is on the septum about half an inch from 
the anterior nares. This point may be touched with silver nitrate or 
other chemical caustics or with the point of a small electrocautery. 

It is often possible for the surgeon to stop the hemorrhage by direct 
pressure on the bleeding point with a small pledget of gauze held in a 
clamp. The direct application of adrenalin chloride solution (1:5000) 
on the gauze pledget mentioned above is an especially effective hemo- 
static. 

If the bleeding continues in spite of the above methods it may be 
necessary to pack the anterior nares. An incorrect method is 
frequently employed and while occasionally successful it is mentioned 
only to be condemned. This method consists of tying a string about 
a ball of cotton forming a tampon which is inserted into the anterior 
nares. It is difficult to get such a tampon as far back as the bleeding 
point, so that when it is really desirable to plug the nares such a tampon 
only plugs the anterior part, the bleeding continuing to flow back into 
the nasopharynx. 

A much better method of packing the cavity of the nose consists of 
passing a narrow strip of gauze well back into the nasal cavity and then 
continuing the process from behind forward so that the entire anterior 
portion of the nasal cavity is filled with gauze. The strip should be 
long enough so that a single strip will suffice, in which case there is no 
danger of leaving a portion of gauze in the nasal cavity. 

If, as is rarely the case, this operation does not control the bleeding, 
the gauze must be removed and a tampon placed in the posterior nares. 
This is extremely disagreeable to the patient and should only be tried 
when other available means have failed. A strong piece of thread is 
fastened to the end of a soft rubber catheter, which is passed through 
the bleeding side of the nasal cavity until the end of the catheter can 
be seen in the back of the throat. The string is caught with a hook and 
drawn out of the mouth. The catheter is withdrawn, the result being 
that the patient is left with a string passing into the nose and out 
through the mouth. A cotton tampon about the size of a walnut is 
fastened to the string, the end of which is left about eight inches long. 



FOREIGN BODIES IN HEAD AND FACE 



117 




Fig. 46. — Plugging the posterior nares. 
(Ashhurst) 



Traction made upon the string passing through the nose draws the 
tampon through the mouth and nasopharynx and firmly into the 
posterior nares. The two ends of 
the string are tied together so that 
the plug may be removed from the 
posterior nares when desired, and 
the anterior nares packed accord- 
ing to the method described above. 
This procedure if properly carried 
out will check even the most per- 
sistent bleeding from the nose. 

When once packed, the plugs in 
the anterior and posterior nares 
should not be disturbed for two or 
three days . If removed before this 
time, the gauze, which is still ad- 
herent to the bleeding point, pulls 

away the protecting clot and the hemorrhage is likely to recur. After 
three days have elapsed, the natural secretions from the mucous 
membrane have caused the plugs to become loosened and they are 
easily removed. 

FOREIGN BODIES IN THE HEAD AND FACE. 

In the head and face there are several cavities which, from their 
exposed condition, are especially prone to injury due to the introduction 
of foreign bodies, such as splinters of glass, wood, or other material 
beneath the skin of the face or scalp. In penetrating wounds foreign 
bodies may be introduced. They should be removed by incision as 
they almost always finally lead to suppuration when they are allowed 
to remain. The wound should be swabbed out with tincture of iodine 
and sutured, unless infection has been introduced, in which case the 
wound should be opened widely and allowed to heal by granulation. 
Owing to the excellent blood supply of this region, foreign bodies have 
been known to remain in the tissues of the head and face for months 
or years without causing suppuration. 

Bullet wounds of the face are common. They should be swabbed 
with tincture of iodine and the bullet located by roentgen ray. It is 
almost useless to attempt to probe for a bullet about the face or scalp, 
for the peculiar shape of the bones is likely to deflect the bullet into 
the most unexpected locations. Occasionally the bullet can be felt 
beneath the skin. When the location is accurately determined, the 
bullet should be cut down upon directly and removed. 

Powder Grains in the Skin. — Following explosions, powder grains 
or fine particles of stone or metals may be driven into the skin by the 
force of the explosion. They must be removed, for they are usually 
sterile and likely to remain as dark specks upon the face. 



118 INJURIES TO THE HEAD 

If only a few are present, they may be picked out one by one; but if 
they are numerous, as is usually the case, such a procedure would 
require almost unlimited time and patience. The most satisfactory 
method for accomplishing this is by vigorous scrubbing of the skin with 
a stiff brush. In most cases it is advisable to carry out the scrubbing 
process under general anesthesia. 

After the powder has been present for several days they are much 
more difficult to remove. In cases presenting themselves several days 
or longer, after the injury, the scrubbing process should be carried out, 
removing as many grains as possible while the remainder must be 
removed one at a time with sharp point forceps. 

In still older cases, little can be done except the slow method of 
removing one grain at a time. 

Foreign Body in the Eye. — Small cinders or grains of sand are the 
most common types of foreign body which require removal from the 
eye. In iron-workers, small particles of iron may fly into the eye and 
become imbedded in the eyeball. 

In their removal, it is important to remember that the cornea is 
very sensitive, even the slightest touch causing pain ; while the greater 
part of the conjunctiva is only slightly sensitive. A fairly large particle 
of sand or dirt will cause little or no irritation, unless it comes into direct 
contact with the cornea; while a microscopic grain will cause intense 
pain if located directly upon, or on the lid adjacent to, the cornea. 
Consequently, if the foreign body is located upon the cornea, a few 
drops of 2 per cent cocain or novocain solution should be dropped into 
the eye before the removal is attempted. 

A foreign body should be searched for in a bright light, a small 
magnifying lens being used if direct examination is unsuccessful. The 
upper and lower lids must be everted in order to examine the con- 
junctival surface. When the particle is found, it is wiped away by 
cotton swab (made by wrapping a small amount of cotton about the 
end of a match or toothpick) . Occasionally a minute particle of steel 
or brass will be found so firmly imbedded in the cornea that a small 
pair of forceps is required to remove it. 

After the particle is removed, two or three drops of argyrol (20 
per cent) solution should be dropped in the affected eye and the 
patient directed to wash out the eye every two or three hours with a 
saturated solution of boric acid. The argyrol instillations should be 
repeated two or three times daily until the conjunctival congestion has 
subsided. If there has been much pain, and the eye becomes acutely 
inflamed, the patient should be kept in a darkened room and continuous 
cold boric acid compresses should be applied to the affected eye. 

When foreign bodies are more deeply imbedded in the eye, the patient 
should be referred immediately to an eye specialist. It should be 
remembered that even a slight injury may result in a corneal ulcer. 

In industrial practice where such accidents are common a large 
electromagnet has been found of value in the removal of small particles 



FOREIGN BODIES IN THE MOUTH AND THROAT 119 

of steel or iron from the eye. It is of little value when the fragment has 
penetrated deeply into the tissues. 

Foreign Bodies in the Ear. — Beans, beads and other small objects 
are often found in the ears of children. In adults, flies or small insects 
are the most frequent forms of foreign bodies found in the ear. 

The diagnosis is made by direct inspection. An insect in the 
auditory canal causes a buzzing in the ear which the patient finds 
almost intolerable. After an object has been in the ear for several 
days, the lining membrane of the external auditory canal becomes 
irritated and a discharge results. Frequently in children this is the 
first symptom noticed. 

The best form of treatment is removal with a small pair of forceps 
under direct inspection. In the case of small, hard objects, such as 
beads, the attempt may be made to wash them out with a stream of 
water from a syringe or douche bag; but great care should be taken not 
to introduce water when there is a bean or other like substance present 
which is likely to swell when wet. 

Insects, when alive, will sometimes come out of the ear, if a bright 
light is placed near the opening of the canal; or olive oil poured into the 
ear will at once stop the buzzing and drown them. 

Inspissated wax may form a hard mass in the external ear and act 
as a foreign body. The usual symptoms are ringing in the ear and 
deafness. There is a considerable element of danger in the direct 
removal with forceps or curette, except by an otologist; but removal by 
syringing is usually easy and free from danger. With a large syringe, 
a fine stream of warm alkaline solution is directed into the ear along 
the posterior wall of the canal, and continued until the ball of wax is 
finally washed out. 

This procedure usually requires about a quart of water and ten 
minutes syringing. Bicarbonate of soda (2 per cent) and borax (2 per 
cent) are the solutions generally used. In especially obstinate cases 
a few drops of oil may be dropped into the ear and left overnight to 
soften the plug of wax. 

Foreign Bodies in the Nose. — Children are likely to place the same 
objects in the nose that they place in the ear. If seen early they may 
usually be removed by directing the patient to blow the nose violently. 
If this is unsuccessful, they should be removed under direct inspection 
with a sharp hook or mousetooth forceps. In some cases a wire snare, 
such as is used in nasal operations, can be used to withdraw the foreign 
body. 

In children, the irritation caused is likely to lead to a discharge from 
the nostril. A unilateral nasal discharge is always suggestive of a 
foreign body. Removal is often very difficult when the object is 
imbedded in the mucous membrane, and an anesthetic is usually 
required. 

Foreign Bodies in the Mouth and Throat. — Foreign bodies, such as 
pins and fish-bones, frequently become lodged in the pharynx. The 



120 INJURIES TO THE HEAD 

diagnosis is made upon direct inspection, and removal is accomplished 
by means of a long pair of forceps. The foreign bodies most commonly 
lodge at the base of the tongue or in the tonsil. If the object has 
passed out of the area of direct vision, it may be lodged at some point 
in the lower pharynx or esophagus. The narrowest part of the throat 
is at the level of the cricoid cartilage, and it is here that foreign bodies, 
such as coins and buttons, are likely to lodge. If they can be felt with 
the finger, they may be removed with a pair of long, curved forceps. 

In some cases, the object may be of such a character that it is 
advisable to force it down into the stomach. This is accomplished by 
having the patient swallow a large bolus of bread or other similar food. 
When a pin or other sharp-pointed object is swallowed, it is well to 
give a considerable quantity of coarse food, such as partly cooked 
rolled oats or bran, so that the pin may be carried entirely through the 
intestinal canal in the center of the mass. 

Even if there are no symptoms, every possible effort should be made 
to remove the foreign body from the pharynx or the esophagus; for, 
if it is allowed to remain, it is almost certain to result in ulceration and 
local infection. 

When the object is of sufficient density, a roentgen-ray examination 
will serve to locate its exact position, which is usually at the level of the 
cricoid cartilage or at the cardiac end of the stomach. 

For coins and buttons the esophageal coin-catcher is of great value; 
while pins and irregularly shaped objects may sometimes be removed 
by the use of the bristle probang. 

In expert hands, the esophagoscope will permit direct examination 
and the removal of small objects. 

Foreign Body in the Larynx or Trachea. — Especially in children, 
sudden attempts at inspiration are likely to suck particles of food or 
other foreign bodies into the larynx or trachea. When the foreign 
body touches the vocal cords, they close firmly, causing the patient 
to cough and then gasp helplessly for breath. After a fraction of a 
minute, they relax slightly and air is drawn in slowly with a loud, 
sibilant sound. The foreign body may be expelled, or drawn down 
into the trachea; or it may remain between the vocal cords, firmly 
wedged there by attempts at inspiration. 

Treatment. —The treatment varies with the period at which the 
patient is seen. During the early period of choking, inversion for a 
minute or two or a firm blow with the open hand upon the patient's 
back may be tried. 1 It is well, in obstinate cases, to attempt to 
dislodge with the finger any particles of food which may be obstructing 
the larynx. Unconsciousness, due to asphyxia, will cause the larynx 
to relax when everything else has failed. If this does not occur, an 
emergency tracheotomy must be done at once. 

1 It is well, if possible, to invert the child first and then slap him on the back, as occa- 
sionally cases occur in which the object is disloged only to be drawn back again by gravity 
and the following inspiration. In adults, inversion is impossible but the patient may 
lean forward over a chair. 



WOUNDS OF THE HEAD AND FACE 121 

In cases seen after the foreign body has been present in the larynx 
or trachea for some time, three methods of removal have been advised : 

1. Inversion. 

2. Emesis. 

3. Direct removal. 

The first and second methods have been successful in only a com- 
paratively small number of cases, and are not without danger, because 
the object, which is temporarily giving few symptoms, may be forced 
from the trachea into the larynx and cause fatal asphyxia. 

By far the best plan is direct removal of the foreign body with a 
small alligator forceps under the guidance of the bronchoscope. This 
naturally requires the services of a specialist. 

WOUNDS OF THE HEAD AND FACE. 

Wounds of the Scalp. — Contusion of the scalp is very likely to result 
in a wound, which in some cases penetrates to the skull. The edges 
are often almost as clean cut as an incised wound. Lacerated and 
incised wounds also occur either alone or complicating fracture. The 
chief characteristic is hemorrhage, which is likely to be profuse and 
persistent. 

Treatment.— Before the wound is examined, the surrounding area is 
shaved for about half an inch from the edges of the wound and gross 
contamination, if present, is removed by thorough cleansing of the 
wound with saline solution. Bleeding points on the cut edges of the 
scalp may be clamped and ligated with catgut; but as this procedure is 
likely to be rather difficult on account of the thickness of the scalp, 
it is often better to control whatever hemorrhage is present by means 
of the sutures applied for coaptation. 

After the wound has been well washed out, it is sponged dry and 
inspected for possible fracture of the skull. 1 If no complications are 
present, the wound and the surrounding scalp are swabbed with iodine, 
and the edges are approximated with strong sutures of medium-weight 
silk. The sutures should be close together and more firmly tied than 
is the case in other parts of the body. Drainage is unnecessary, as a 
rule, the ordinary rubber tissue drain serving only as a portal of 
entrance for the introduction of infection. 

If, after a day or two, there is a collection of blood beneath the scalp, 
one end of the wound may be opened slightly with a probe and the 
clots expressed. If signs of infection occur, enough sutures should be 
removed to allow free drainage. It is important to remember that 
redness, heat, and swelling are not usually found in infection of a scalp 
wound. The fact that infection has occurred is shown by increased 
pain, fever, and an area of edema and tenderness, most acute near the 
wound and spreading over the scalp. Early and free drainage of 

1 It is sometimes very difficult to differentiate a linear fracture from an incised wound 
of the thin aponeurotic tendon of the occipitofrontalis muscle. 



122 INJURIES TO THE HEAD 

suppurative wounds is indicated because the pus tends to spread in 
all directions either between the scalp and the occipitofrontalis muscle 
or beneath this muscle. 

Wounds of the Face. — The special indication in these wounds is the 
prevention of disfiguring scars. Accurate coaptation of the cut edges 
and suture with small, fine sutures without drainage is the general rule. 
The wound is cleansed and swabbed with iodine and any irregularly 
lacerated tags removed. 

Treatment.— Interrupted sutures are always used, the best materials 
being either horsehair or silk. The distance between sutures should 
not be more than one-quarter of an inch. Often it is necessary to place 
them even closer together in order to obtain proper approximation. 
If the sutures are removed on the fourth or fifth day, the puncture 
wounds caused by the needle will not be apparent when healing is 
complete. A method which we have used in suitable cases consists in 
the coaptation of the edges by means of buried catgut sutures. Fol- 
lowing this the skin edges are sutured with a small needle and fine silk, 
care being taken not to pass the needle entirely through the skin. 
If the papillary layer is uninjured, there will be no scarring. 

Any form of dressing about the mouth and eyes is likely to become 
moist and easily soiled. Such a dressing does more harm than good. 
In such cases it is a good plan to paint the sutured wound with a 
solution known as " Whitehead's Varnish" (equal parts of compound 
tincture of benzoin and a saturated solution of iodoform in ether), 
which dries and forms a protective coating over the wound. Its 
usefulness is increased and the wound made less noticeable, if a little 
powdered aristol is dusted over the surface before the varnish dries. 

Flexible collodion may be used for the same purpose but is of less 
value because, if there is any discharge from the wound, the collodion 
is firm enough to prevent its escape, while the varnish, mentioned 
above, although effective in keeping dust and dirt out of the wound, 
does not offer any appreciable obstacle to the escape of any possible 
discharge. 

Wounds of the Mouth. — Not infrequently, the surgeon is required 
to treat a ragged wound of a tongue which has been accidentally bitten. 
If the wound requires sutures, black silk is the material of choice. 
Sutures should remain in for at least a week and the mouth should be 
cleansed with a mild antiseptic mouth wash. Suppuration is rare. 

Wounds of the mucous membrane of the lips are frequently associ- 
ated with wounds of the external surface of the lips or cheeks. These 
wounds should be sutured just as carefully as wounds in other parts 
of the body. While serious infection of wounds of the mouth is rare, 
under the ordinary methods of treatment, it is not at all uncommon 
in wounds which have not been sutured. 1 Black silk sutures which 

1 Very rarely severe infections follow untreated wounds of the mouth. A fatal case 
of noma seen by the writer followed a neglected wound of the mucous membrane of the 
mouth. 



BURNS OF THE HEAD AND FACE 



123 



can be easily seen and removed, are generally used. Cicatricial 
contractions following wounds of the mouth result in secondary 
deformities or stricture of the parotid duct. 

In wounds of the tongue or mucous membrane of the lips or cheeks, 
suppuration, when it occurs, is very rarely an indication for removal 
of the sutures. The constant moisture in which these wounds are 
bathed makes for free drainage from the wound between the points 
of suture. 

Wounds of the Eye, Nose and Ear. — Wounds of the external portions 
of these organs are treated in the same manner as wounds of the face. 
If the conjunctiva is cut, it should be sutured with fine catgut, after 
preliminary washing with 2 per cent boric acid solution. Unless there 
is considerable hemorrhage, it is better to leave the eye unbandaged. 
The treatment of deeper wounds of the eye and deep, penetrating 
wounds of the nose and internal ear is to be found in works dealing 
with these specialties. 




Fig. 47. — Chronic ulcer of scalp, following burn from celluloid comb explosion. 

tion, five months. 



Dura- 



BURNS OF THE HEAD AND FACE. 



Localized burns of the face are treated in the same manner as burns 
in other parts of the body. Generalized burns of the face and neck, 
because of the fact that they are usually unprotected by clothing, are 
of frequent occurrence. They may be due to escaping steam, exposure 
in burning buildings, and gas explosions. Because of the protection 
afforded by the hair, the scalp is rarely burned to the same degree as 
the face. In most cases the injury is limited to second degree burns, 
third degree burns being less frequent. 

Treatment.— On account of the pain, a protective dressing is neces- 
sary during the first few days. Sterilized borated vaseline is a most 



124 INJURIES TO THE HEAD 

satisfactory application. The ointment is smeared over the face and 
covered with a few layers of gauze in which holes have been cut for the 
eyes, nose and mouth. This dressing should be changed daily, as 
burns of the face are very likely to become infected. 

Just as soon as possible, it is advisable to leave burns about the head 
exposed to the open air. After cleansing the burned area, it is dusted 
with boric acid or aristol and left completely exposed, the moist areas 
drying in a comparatively short time. Crusts which form should not 
be removed until healing is complete, unless they show indications of 
the retention of a purulent discharge in which case they should be 
softened with petrolatum and removed. 

In burns about the mouth, eyelids, and neck, massage and motion, 
both active and passive, should be begun when healing is complete 
and continued for months to prevent contraction. If contraction is 
threatened, the patient should be taught daily exercises which stretch 
the scar in the direction opposite to which the contraction is taking 
place. 

Burns of the Mouth. — In burning buildings, the flames are some- 
times inhaled, the result being burns of the mouth, larynx and trachea. 
These injuries, when they involve the trachea, are nearly always fatal. 
Where the edema is limited principally to the larynx, tracheotomy or 
intubation may give relief. Usually the trachea and bronchi are 
involved, resulting in bronchopneumonia. The treatment is symp- 
tomatic. It is especially important that the mouth be kept clean, as 
an ascending infection of the parotid gland through the duct, or of the 
internal ear through the Eustachean tube, is not uncommon in neglected 
cases. 

In local burns of the mouth, as occasionally seen after the ingestion 
of hot foods, an alkaline mouth wash, such as a 2 per cent solution of 
sodium bicarbonate, usually gives relief. 

Burns of the Eyes. — Burns of the eyes are seen especially after gas 
or powder explosions. These patients should be kept in a darkened 
room and the eyes bathed frequently with the soda solution above 
mentioned. Drops of castor oil may be used during the early period 
of pain. The pain may also be relieved by the application of cold 
compresses. Chemical burns of the eyes are of frequent occurrence. 
The commonest of these are caused by lime splashed in the eye during 
the process of slaking. These burns often result in deep ulcerations 
that later form adhesions. The lime should be washed out with a weak 
solution of vinegar in water (J to 1 per cent) and all the particles of 
lime removed. This is followed by a few drops of a 1 per cent solution 
of carbolic acid in alcohol which relieves the pain and prevents suppura- 
tion. When the burns are caused by an acid being thrown or splashed 
in the eye, an alkaline solution should be used in washing out the eye 
to neutralize the acid. 

Chemical Burns of the Face. — Carbolic acid burns are seen about 
the lips and mouth in cases of attempted suicide. They are rarely 



FRACTURE OF THE SKULL 125 

deep and ordinarily require no treatment except the initial washing with 
alcohol. 

Acid and alkali burns occur in factory workers and occasionally as 
the result of intentional injury. They should be neutralized as soon 
as possible and then treated with a bland ointment. 

"Mustard Gas" Burns. — During the war there were a great many 
casualties due to the effect of irritating gases. One of these, commonly 
called " mustard gas/' caused severe burns about the face, mouth, 
larynx, and trachea. Most of the severely burned, especially those 
in whom the trachea was involved, died about the third or fourth day 
with symptoms of membranous tracheitis and bronchitis. 

Some patients showed severe burns about the eyes and face with 
only slight laryngeal and tracheal symptoms. Under these conditions, 
recovery was the rule. The pain about the eyes was extremely severe, 
sometimes requiring morphine for its relief. There w r as always an 
associated conjunctivitis. 

Treatment. —The treatment consists in the removal of all clothing 
which may be impregnated with the gas and the use of warm water to 
wash away any of the excess of the liquid gas which may be present. 
The patient should be placed in bed and kept quiet until all symptoms 
have disappeared, the inflamed areas being bathed with bicarbonate 
of soda solutions. Irritation of the conjunctiva may be complained of 
for many months after the other symptoms have disappeared. 

FRACTURE OF THE SKULL. 

In any injury to the skull, the possibility of an associated fracture 
must be kept firmly in mind. Wounds of the scalp must be carefully 
inspected, and contusions of the scalp must always be considered as 
possible evidences of fracture of the skull. 

Severe head injuries showing unmistakable evidences of fracture 
(unconsciousness, paralysis, hemorrhage from the nose or ears, etc.), 
are usually easily diagnosed and the indications for treatment are 
definite. 

Of comparatively more consequence, because of their great frequency, 
are head accidents in which the symptoms are only those of what is 
apparently a minor injury. It is a safe rule to regard every injury to 
the head as a potential fracture of the skull until the contrary has been 
proved. 

Given an injury to the scalp caused by a blow r either with or without 
an associated wound, how is the presence or absence of a fracture to be 
diagnosed ? 

An absolutely accurate diagnosis is manifestly impossible. Many 
cases show symptoms of cerebral injury without fracture, and other 
cases show T distinct fracture without any development of intracranial 
disturbance. The roentgen ray is of value as an aid to diagnosis in 
certain cases. However, a negative result does not exclude fracture, 



126 



INJURIES TO THE HEAD 



The following rules are valuable and should be kept in mind in the 
treatment of all head injuries: 

1. Every head injury should be kept under observation, preferably 
at rest, until several hours have elapsed after the accident, in order to 
guard against the late development of the symptoms of intracranial 
injury. 

2. Every scalp wound should be carefully inspected for direct 
evidence of fracture. Care should be taken not to mistake for fissure- 
fracture the torn or cut periosteum, which when fresh usually bleeds 
freely and resembles fracture. The cut tendon of the occipitofrontalis 
muscle also resembles fracture. 




Fig. 48. — Fracture of vault and occiput, following fall on back of head. 



3. When symptoms of intracranial injury (dizziness, nausea, and 
vomiting, inequalities of the pupils, paralysis, and unconsciousness) 
are present, the case should be considered as fracture and treated 
accordingly. 

4. When fissure-fracture without general symptoms is found, there 
are no special indications other than the general care of the patient. 
As a precautionary measure, these patients should be put to bed for 
a week or longer; but many of them, feeling perfectly well, refuse such 
treatment and seem to recover without ill effects. 

5. If depressed fracture is found, even if the depression is slight, 
operation for the elevation of the fragment is indicated in every case. 

6. If there is hemorrhage from the nose or ears (especially from the 



FRACTURE OF THE SKULL 



127 



ears) or ecchymosis about the eyes, either with or without general 
symptoms, fracture of the base of the skull should be suspected. 

7. Remember that even when an open wound which allows inspection 
of the skull shows no fracture, the blow may have caused a fracture at 
another point, the so-called " fracture by contrecoup." 

The immediate treatment of wounds communicating with fractures 
is important. In fissure-fracture of the vault, the wound should be 
swabbed out with tincture of iodine and sutured. 

In depressed fracture of the vault, the wound is swabbed with 
iodine and a dry dressing applied until preparation can be made for 
operation. 




Fig. 49.— Roentgenograph of skull fractured by blow. Woman, aged thirty-five years. 



In fracture of the base, the patient is put to bed in a darkened room, 
an ice-cap is placed on his head, and sedatives or stimulants are given 
as indicated. If there is bleeding from the ear, the auditory meatus 
and the entire external ear are swabbed with tincture of iodine. A 
dry dressing is applied and changed as often as it becomes moist. 
Urotropin may be given in large doses for its possible antiseptic effect. 
Where symptoms of shock are not too great, the head of the bed should 
be elevated so as to relieve the intracranial pressure. 

In any of these cases signs of increased intracranial pressure may 
develop and require relief by decompression. 



128 



INJURIES TO THE HEAD 



FRACTURES ABOUT THE FACE. 

Fracture of the Nose. — This includes the nasal bones, the nasal 
process of the superior maxilla, and the septum of the nose. 

On account of the associated swelling, the deformity is not always 
immediately apparent. The movements and crepitus of the nasal 
bone are sufficient evidences of fracture. 

Treatment.— The treatment is directed toward the correction of 
the deformity. In simple, lateral displacement it is sufficient to 
correct the deformity by pressure toward the other side. 




Fig. 50. — Fracture of nasal bone caused by blow. 

When the bridge of the nose is depressed, it must be raised by a small, 
firm instrument inserted within the nose and direct pressure made 
against the posterior surface of the bone. An ordinary urethral sound 
of a suitable size is usually at hand and is ideal for this purpose. 

The nasal cavity should always be inspected, and if the septum is 
found displaced it should be reduced. A pair of forceps with long nar- 
row jaws preferably covered with rubber, may be used for this purpose, 
one branch being introduced into each nostril, thus permitting a firm 
grasp on the septum, which once reduced may be held in place by 
packing in the nasal cavity into which it was displaced, 



FRACTURES ABOUT THE FACE 



129 



A dressing for fracture of the nose is usually unnecessary, a pad 
strapped on one side of the nose with long strips of adhesive which pass 
from cheek to cheek may have a slight influence to prevent displace- 
ment. It is best to see the patient daily for the first week, reducing 
any slight amount of displacement as soon as it occurs. In some types 
of injury, the use of an intranasal splint may be required to hold the 
bones in place. These splints, acting as foreign bodies, are likely to 
favor the development of infection. In most cases their use may be 
safely dispensed with. 

Healing is firm in ten days, and apparently complete in about three 
weeks. Although these fractures are almost always compound, 
suppuration is very uncommon. The use of intranasal antisepsis is 
unnecessary in ordinary cases. In the rare fracture accompanied by 
suppuration, surgical treatment is indicated. 




Fig. 51. — Abscess of the frontal sinus, broken through. Secondary to fracture. 



Fracture into the Frontal Sinus. — The outer wall of the frontal sinus 
may be fractured and depressed. Reduction is necessary to prevent a 
disfiguring deformity. It may be accomplished by means of a sharp 
hook inserted through a small incision, or by means of an open opera- 
tion through an incision just below and parallel to the eyebrows. 

Fracture of the Malar Bone. — In injuries associated with swelling 
of .the cheek, a careful examination may show depressed fracture of the 
malar bone. Early recognition is important, because unless corrected, 
after the swelling subsides there will be a disfiguring deformity which 
may then be irreducible. 

The displacement takes place usually in two directions, depression 
and rotation inward on an antero-posterior axis. The depression can 
be plainly felt in the margin of the orbit at the location of the intra- 
orbital foramen. 

The fracture is reduced by making an incision just behind the 
9 



130 INJURIES TO THE HEAD 

posterior-inferior border and by inserting a blunt hook, through the 
masseter muscle, traction is made in the direction necessary to bring 
about reduction. This method of traction tends to throw the depressed 
margin of the orbit upward and outward. Additional traction may be 
secured by a second hook inserted through the skin into the bone at 
the margin of the orbit. Fixation is unnecessary, the bone remaining 
in place once it is reduced. 

Fracture of the Superior Maxilla. — The superficial situation of the 
superior maxilla permits diagnosis in practically every case by direct 
inspection and palpation through the mouth. 

Reduction is generally accomplished by manipulation. In some 
cases blunt or sharp hooks may prove of value. Healing is rapid with 
a very small amount of callus. Suppuration in these fractures, which 
are often compounded into the mouth, is rare. Consequently, it is the 
general practice to leave every fragment which is not entirely detached. 

When the alveolar process is fractured, it should be pushed back 
into place with the finger and held there by wiring the teeth in the 
fragment to the adjoining teeth, or by the use of an interdental splint. 

Fracture of the Zygomatic Arch. — The arch may be broken by direct 
violence, the fragment being forced inward. If unreduced, a per- 
manent depression will result and the movement of the jaw may be 
interfered with. 

Unless there is marked swelling, the depression can be felt by direct 
examination. Crepitus is occasionally obtained on movement of the 
jaw. 

Manual reduction is impossible, but the arch is easily replaced by 
traction with a sharp hook introduced through a small incision in the 
skin. Another method of reduction consists of passing a strong 
suture on a curved needle beneath the arch, thereby securing traction. 
If the displacement recurs when traction is released, the ends of the 
suture may be tied over a small splint for several days. If this opera- 
tion is performed under aseptic precautions, there is no danger of 
infection. 

Fracture of the Mandible. — A frequent form of fracture of the 
mandible is fracture of the alveolar margin, which may be broken by 
direct injuries, as from a blow, or in the extraction of teeth. This 
fracture is usually treated by dentists or dental surgeons. 

The fracture which commonly comes under the care of a surgeon is 
the vertical fracture of the body of the jaw, usually about the location 
of the bicuspid teeth. Fractures of the ramus and condyloid process 
may occur either alone or in connection with fracture of the body of 
the jaw. As the larger part of the bone is superficial, the injury is 
likely to be compounded into the mouth. However, only a com- 
paratively few cases go on to suppuration and necrosis. 

In fracture of the body of the jaw, the bony irregularity can be seen 
and felt by examination of the alveolar margin from within the mouth, 
and by the irregularity of the teeth, In fracture without displacement, 



FRACTURES ABOUT THE FACE 



131 



the diagnosis rests on localized tenderness and pain on biting. These 
two latter symptoms are of value in fracture of the ramus and of the 
condyloid process. 

The anterior border of the ramus can be palpated throughout the 
greater part of its extent by a finger inserted into the mouth. The 
condyloid process is felt to move when the jaws are opened at a point 
just anterior to the external ear. When it is fractured (transverse 
fracture of the neck), the articular process does not move forward as 
the jaw descends. 

Treatment.— In fracture of the alveolar process the fragment should 
be forced back into place with the fingers and held in place either by 
pressure of the upper teeth, when this is feasible, or by wiring the teeth 
in the broken process to the sound teeth on either side, or by the use of 
an interdental splint. 




Fig. 52.— Oblique fracture of mandible following blow on chin. 



In fracture of the body, the displacement is reduced manually as 
soon as the fracture is seen and the jaw bound against the upper teeth 
with a suitable bandage. If there is tendency to displacement, the 
fixation must be made permanent either by wiring the sound teeth on 
both sides of the fracture so as to support the bone at the point of 
fracture or by the use of an interdental splint which fits between the 
teeth of the upper and lower jaws. During the use of the fixation 
apparatus (two or three weeks), the patient must be fed on fluids taken 
through a tube. Frequent lavage of the mouth with a suitable anti- 
septic lotion is advisable. 



132 INJURIES TO THE HEAD 

When the ramus or the condyloid process is fractured, a bandage 
furnishes sufficient mobilization. 

It is important to save as much of the jaw and as many teeth as the 
injury will permit. Unless the fragment of the bone or tooth is entirely 
detached, it is better to force it back into place and to wait until a 
later date for extraction, if it is then required. The jaws, in many 
cases in which there is apparently no possibility of union, will heal 
kindly. In addition to this, the removal of a partially detached 
fragment may be enough to interfere with the blood supply of a frag- 
ment more deeply situated. 

The interdental splints are made of metal, gutta-percha, or rubber. 
They may be secured from dental supply manufacturers, being made 
from a plaster cast of the teeth, and may include simply the lower 
teeth or those of both the upper and lower jaw. Unless the surgeon 
has had experience in work of this sort, it is better to have the cast 
made by a competent dentist. During the recent war, fractures of the 
jaws were treated almost exclusively by dentists and dental surgeons. 
During the use of the interdental splint the patient should be fed solely 
on fluids. When the splint is applied, it is wise to make provision for 
feeding. If there is a tooth missing, the space left will allow the 
admission of a tube ; or, the splint may be so arranged as to leave a small 
space for feeding. 

As the large majority of fractures of the jaws are compounded into 
the mouth, a certain degree of infection is not uncommon. When 
severe infection occurs, the usual history notes increased pain on the 
third or fourth day after the fracture, followed by a purulent discharge 
into the wound. This condition requires no special treatment except 
lavage of the mouth. It usually goes on to granulation, and healing 
is only a little delayed. In other cases, either from the first or after 
several days or weeks of free drainage, there is retention of purulent 
material with induration and swelling of the surrounding tissues. Such 
cases require free drainage by incision through the mucous membrane 
of the mouth or through the skin. If the incision is made externally, 
it should be made parallel to, and just below, the border of the jaw, 
care being taken not to wound the facial artery and vein. 

A common result of these infections is for a sinus to persist for several 
weeks. If union is fairly firm, the splint may be dispensed with, and 
the patient allowed slight use of the jaw. At any time the sinus is 
liable to obstruction with consequent retention of pus. When this 
occurs, the opening should be enlarged and the particles of necrosed 
bone removed. 

If the sinus persists for several months under this plan of treatment, 
a roentgen ray should be taken; and if a sequestrum is evident, it should 
be removed by operation. 

Dislocation of the Mandible. — Dislocation may be either bilateral 
or unilateral, the former being the ordinary type in which the two 
condyloid processes slip forward over the surfaces of the articular 
eminences. 



INFLAMMATION OF THE FACE AND SCALP 133 

The accident occurs when the mouth is opened widely, as in laughing, 
yawning, vomiting, etc., the mouth being fixed in the open position, 
the lower jaw immovable and slightly projected forward. 

Treatment.— Reduction is accomplished by pressure of the thumbs 
upon the posterior molars. The surgeon places his thumbs, wrapped 
in gauze, against the grinding surfaces of the molars and grasps the 
two horizontal rami of the jaw with his hands; the jaw is now opened 
a little wider, while the patient attempts to relax the muscles and 
pressure, backward and slightly downward, is made upon the molar 
teeth. 

When reduction occurs, the teeth come together with a snap which 
is often powerful enough to injure the surgeon's thumbs if they are not 
protected. Consequently, before the manipulation is begun, the 
thumbs should be well wrapped with gauze to protect them against 
injury. If the above maneuver is not successful, it should be repeated 
under anesthesia. After reduction a loose bandage should be applied 
so as to prevent the mouth being opened widely. This bandage should 
be left in place for about a week. In very few cases the intra-articular 
fibrocartilage may act as a hindrance to reduction and may require 
removal by open operation. 

INFLAMMATION OF THE FACE AND SCALP. 

Simple Herpes. — Simple herpes, common about the region of the 
mouth, is an acute inflammatory eruption, vesicular in character, 
which occurs frequently at the beginning of an acute disease, particu- 
larly malaria and lobar pneumonia. 

Treatment.— When the vesicles first appear, they should be painted 
every hour with alcohol or spirits of camphor. This treatment will 
occasionally abort them before they fully develop. Ordinary house- 
hold ammonia is often successfully used in the same manner. When 
the contents become cloudy, they should not be opened but allowed 
to dry up unbroken. 

Herpes Zoster. — This is characterized by a painful vesicular eruption 
along the course of a superficial sensory nerve. It is not uncommon 
about the face and neck and must be differentiated from simple herpes 
and impetigo. 

The eruption is usually preceded by an acute neuralgia, which persists 
for two or three days before the vesicles appear. The vesicles usually 
dry up without suppuration, unless they have been broken and infected 
from without. 

Treatment.— The local treatment aims only at the prevention of 
infection. The vesicles are painted with collodion or dusted with 
powder. As ointments tend to soften the vesicles and facilitate 
rupture and infection, they should never be used. If suppuration 
occurs, the condition is essentially a superficial ulceration and should 
be treated with wet dressings and antiseptic lotions. The neuralgia 



134 INJURIES TO THE HEAD 

requires internal medication for the relief of pain. A single application 
of the roentgen ray will often cause almost instant relief of pain. 

Impetigo Contagiosa. — This is an acute pustular eruption of the skin 
and almost always occurs about the mouth and chin. The lesion may 
be transferred to other parts of the body by scratching, clothing, or 
towels. 

If the crusts are carefully removed, the vesicles opened, and the skin 
kept clean, the lesions will usually rapidly disappear. Ammoniated 
mercury ointment (one-half strength) applied twice daily will effect a 
cure in a few days. In obstinate cases the application of roentgen 
rays will sometimes effect a rapid cure. 

SEPTIC INFECTIONS OF THE FACE AND SCALP. 

Boils and Furuncles. — Furuncles occur frequently upon the face. 
In the region of the mouth or eyes, the loose character of the tissue 
leads to extensive edema. Occasionally a patient is seen with a 
markedly swollen lip which is tender, but which shows no external 
signs of inflammation. If such a case is due to a boil, the tender 
indurated area may be detected by palpation with one finger intro- 
duced into the mouth. Boils of the upper lip are said to be especially 
dangerous because the infection may spread along the veins into the 
cavities of the skull. 1 

Boils about the eye may cause sufficient swelling to close the eye 
completely. It is important not to mistake this surrounding edema 
for cellulitis. Except for the immediate area surrounding the furuncle, 
there is no tenderness or redness, the swelling being largely the result 
of simple edema. 

Furuncles of the nose are different in appearance from furuncles 
elsewhere for, owing to the structure of the tissues at the end of the 
nose, the typical lesion is not seen. Infection usually occurs through 
a hair follicle, and the patient first notices a soreness about the end 
of the nose. The soreness steadily increases and the nose gradually 
becomes swollen, red, and extremely tender. At this stage, the nose 
has the appearance of acute erysipelas, but there is usually more acute 
tenderness and the border is less distinct than in the case of erysipelas. 

General symptoms with malaise and fever are present in boils of the 
nose much more frequently than boils occurring in other parts of the 
body, but they are not so marked as in erysipelas. Usually a severe 
boil of the nose causes a temperature of 100° to 101° F., while in 
erysipelas the temperature is likely to reach 104° F. or even higher. 
When the furuncles rupture early, they usually rupture into the nose. 
When they develop further without rupture, the end of the nose may 
be swollen nearly to the size of an egg and rupture may then take place 
either externally or internally. 

1 The writer has never seen this occur. It is very liable to follow carbuncle of the 
upper lip. 



SEPTIC INFECTIONS OF THE FACE AND SCALP 



135 



Infected fissures at the margin of the nose are sometimes surrounded 
by an area of redness and inflammation simulating a boil. The ap- 
plication of tincture of iodine once or twice daily will cure these 
infected fissures. 

Furuncle of the Ear. — Not uncommonly a furuncle develops in the 
external auditory canal. The result is severe pain and deafness, if the 
canal is completely blocked. Occasionally the discharge from the 
canal may be confused with the pus from an otitis media. Usually 
the boil ruptures and discharges externally, but occasionally on account 
of the blocking of the canal the discharge may be forced toward the 
middle ear. 

Treatment. —Any boil in the region of the face which can be diagnosed 
should be opened. There is no question as to the best time for the 
incision. As soon as the boil can be felt as a hard, shot-like mass 
beneath the skin, it should be incised. The question of a scar should 





Fig. 53. — Edema of the eyelid, following mild 
infection of eye of two days' duration. 



Fig. 54.— Abscess of the eyelid of 
five days' duration. 



not be allowed to interfere with the operation. The earlier the boil 
is opened, the smaller will be the resulting scar. It is important to 
remember that practically every boil about the face can be opened 
through a comparatively small incision. In the smallest furuncles, 
a sufficiently large incision can often be made with a large Hagedorn 
needle. This is pushed directly into the minute cavity, which is 
practically always present at the center of the boil, and a small drop of 
pus will be expelled. This may be sufficient to abort the boil, but 
this minute incision soon becomes clogged with dry blood and secretion. 
In these cases we have found it of value to introduce the point of a 
sterile toothpick, previously dipped in tincture of iodine or pure car- 
bolic acid, through the puncture wound into the small abscess-cavity, 
daily or in very acute cases twice daily. This permits the pus to be 
discharged and the development of the boil ceases abruptly. 

When the nose is involved, it is usually possible in the early stages 



136 



INJURIES TO THE HEAD 



to find the acutely tender point of infection (within the nose) by pres- 
sure with the end of a probe. This being found, a small incision is 
made with the end of a scalpel, and the wound kept open as described 
above. In the more fully developed cases it may be impossible to 
locate the center of infection within the nose, in which case the point 
of greatest tenderness on the nose is determined (there will be no 
evident fluctuation), and an incision is made through the skin at this 
point about ye of an inch in length. If pus is not immediately apparent 
the wound is kept open for a day or two, cold compresses being applied 
to the nose, until finally the discharge commences or evidences of 
pointing occurs elsewhere, in which case a second incision should be 
made. In certain cases with considerable brawny induration and no 
evidence of pus formation we have made the incision at the muco- 
cutaneous junction of the nostril and split the two layers from below 
upward. This gives excellent drainage and the resulting scar is 
inconspicuous. 

Boils of the external auditory canal should be incised as soon as they 
occur so that they may drain freely. 

On the cheeks and lips and about the eyes, even with fairly large 
boils, the incision need not be larger than | of an inch, if care is 
taken to keep the wound open and prevent the retention of the 
discharge. 




Fig. 55. — Sty (hordeolum), multiple, recurrent. 



Sty or Hordeolum. — A sty, or hordeolum, is a small boil about a lash 
in either the upper or lower eyelid. If untreated it may become as 
large as a small marble. A sty ruptures spontaneously after several 
days and discharges through an opening at the edge of the eyelid. 
Recurrences are common. 

Treatment.— Occasionally a sty may be aborted by cold applications. 
When fully developed there is usually a soft spot about the center 
where a puncture may be made with a large Hagedorn needle. As 
this procedure is no more painful than the injection of cocain, pre- 
liminary local anesthesia is unnecessary. Hot boric acid compresses 
relieve the pain and hasten absorption. As the pus is certain to 
contaminate the conjunctival cavity, daily instillations of argyrol 
solution (20 per cent) are of value in preventing conjunctivitis. A 



SEPTIC INFECTIONS OF THE FACE AND SCALP 



137 



bandage is contraindicated because it causes a retention of purulent 
material in the conjunctival sac and may lead to serious conjunctivitis. 
Carbuncle. — Carbuncles are fairly common on the face, and are likely 
to be much more serious than carbuncles elsewhere. This is especially 
true of carbuncle of the upper lip which may result in intracranial 
complications through the spread of infection along the vessels. They 
may cause general sepsis and pyemia. 1 They are frequently associated 
with diabetes. Carbuncles of this region require prompt and radical 
excision. In spite of the possibility of disfiguring scars, free excisions 
of every carbuncle of the face should be insisted upon. The technic 
is as outlined under carbuncle of the neck. 




Fig. 56.— Carbuncle of cheek, fatal. 



Cellulitis. — Cellulitis of the Scalp.— Cellulitis of the scalp is especially 
important and differs considerably from cellulitis elsewhere. Redness 
and induration are generally absent, the only symptoms being edema 
and tenderness. Suppuration from a wound of the scalp spreads along 
the cranium either below or above the occipitofrontalis muscle, and as 
there is little subcutaneous tissue there is only a slight amount of 
swelling, the infection spreading laterally beneath the scalp. As the 
area of infection is tender to firm pressure, it is easy to outline. There 
is usually slight edema over the same area. There may be marked 
general symptoms with fever and prostration; but in some cases the 
general symptoms are negligible, even with what appears to be a fairly 
extensive process in the scalp. 

In cellulitis of the scalp it is usually possible to find the point of 
infection, often a small wound showing little or no discharge. In a 
few cases it is impossible to find any abrasion or scratch which might 
serve as an entrance for bacteria. In such cases the cellulitis may 
have spread from the forehead or neck or may have resulted from an 

1 Two cases which have come under our observation developed septic infarcts of the 
kidneys. A carbuncle over the mastoid region caused meningitis. 



138 



INJURIES TO THE HEAD 



infected hair follicle or sebaceous gland. We have seen a severe and 
rapidly fatal cellulitis of the scalp follow a mosquito bite on the bridge 
of the nose which had become infected by scratching. 




Fig. 57. — Edema and cellulitis of inner angle of eye, secondary to dacryocystitis, three 

weeks' duration. 

At certain locations in the calvarium small veins (emissary veins) 
pass into the cranial cavity connecting the veins of the dura with those 
of the scalp. By this means the infection may pass from the scalp 
into the dura and a complicating meningitis occur. 




Fig. 58. — Chronic cellulitis of ear in girl baby, following puncture of ear for ear-rings 

after birth. Duration, seven months. 

Treatment.— The point of entrance, if found, is opened widely for 
drainage, not omitting to enlarge the opening in the aponeurosis, if 
one exists. If this does not cause the swelling and the tenderness to 
diminish within twenty-four hours, the scalp should be opened by 
multiple incisions and a large wet dressing applied. If meningitis 
occurs, the prognosis is uniformly bad. 



SEPTIC INFECTIONS OF THE FACE AND SCALP 139 

Cellulitis of the Face.— This condition resembles erysipelas and must 
be distinguished from it. In cellulitis the general symptoms are 
usually less marked and the border is not raised above the level of the 
skin. In addition to this, there is generally a localized collection of 
pus. The treatment is incision and the application of wet dressings, 
as in cellulitis elsewhere. 

Ringworm of the Scalp (Trichophytosis Capitis). — Ringworm in 
general is easy to cure, but where there are numerous deep hair follicles, 
as in the beard, scalp, and axilla, it is very resistant to treatment. 

Ringworm of the scalp is present almost exclusively in infants and 
children, and is rarely found after puberty. It consists usually of one 
or more lesions, which may be as small as a dime or may cover the 
entire scalp. The larger lesions are formed by the coalescence of the 
smaller ones. The skin covering the patches is scaly. The patches 
are not completely denuded of hair, but are studded with stumps of 
broken hairs and split ends. As ringworm of the scalp is only moder- 
ately itchy, deep scratch-marks are seldom seen. Microscopic exami- 
nation shows the fungus in the hair shaft. 

Treatment.— In this region the hair covering the patch should be 
epilated, the surface scrubbed with tar soap and water to remove 
all scales, and a parasiticide ointment or lotion used. We do not advise 
the use of tincture of iodine in this region, for if persisted in long enough 
to cure the disease it will more or less permanently destroy the hair 
follicles. Roentgen-ray treatment has given good results in ringworm, 
as it has in many of the infectious skin lesions. 

Abscesses. — Localized abscesses are rather rare about the face 
because of the great vascularity of the tissues in this region. For the 
same reason, they usually heal rapidly when a small incision is made. 

Alveolar Abscess.— This condition results from infection about the 
root of a tooth. It usually starts as a violent, throbbing toothache 
which is followed by swelling and tenderness above the alveolar margin. 
Practically every severe throbbing toothache (the old fashioned ulcer- 
ated tooth) indicates pus formation in the unyielding tooth socket. 
The pus having formed may discharge through the root canal of the 
decayed tooth or between the tooth and the gum, in which event the 
condition is rarely seen by the surgeon. In other cases the pus may 
dissect up the periosteum and appear beneath the mucous membrane 
at the side of the alveolar process; or it may cause a localized osteo- 
myelitis of the alveolar process and perforate directly through the bone 
to the external surface of the bone (rarely to the internal) ; or it may 
extend along the body of the bone causing an extensive osteomyelitis 
of the jaw. 

It is extremely important to find the tooth which is at fault, for the 
patient usually refers the pain to the entire jaw. This is done by 
tapping the teeth of the affected jaw with a small metal instrument, 
the diseased tooth being much more painful than the others. In 
addition to this, there is local tenderness on firm pressure on the 



140 



INJURIES TO THE HEAD 



alveolar margin at the site of the affected tooth. The roentgen ray 
is of great value in these cases, the abscess cavity showing as an irregu- 
larly shaped pocket about the root of the affected tooth. 




Fig. 59.— Alveolar abscess, lower early. 



A secondary abscess of the regional glands may complicate an 
alveolar abscess, even when the source of infection is so insignificant 
as to escape ordinary examination. It should be remembered that the 
lymphatics of both the upper and lower jaw drain into the nodes in the 





«* k 


■■■■■:;. jW 1m 


" JKL 


M 




Fig. 60. — Abscess of buccal lymph- 
node. Duration, nine days. 



Fig. 61. — Sebaceous cyst behind the ear. 
Infected, forming abscess. 



neck below the body of the mandible, and that the infection of the 
glands below the angle of the jaw may have its source in the teeth of 
either the upper or lower jaw. An alveolar abscess of the upper jaw 



SEPTIC INFECTIONS OF THE FACE AND SCALP 



141 



may break into the antrum and cause a chronic septic infection of this 
cavity. 

Treatment.— The treatment varies according to the period at which 
the abscess is first seen. While the pus is still confined to the root- 
cavity, treatment by a competent dentist is indispensable. The pus 
should be evacuated either by extraction of the tooth or by means of a 
hole drilled through the root canal into the suppurating cavity. In the 
majority of cases this is sufficient to release the tension and allow 
healing; although it is usually necessary to remove the tooth, even when 
the preliminary drilling of the root has caused relief of pain. 

In a later stage, after the pus has burrowed beneath the periosteum 
to a point where the swelling and tenderness may be easily recognized, 
it may be evacuated by incision and drainage through the mucous 
membrane of the mouth. 




Fig. 62. — Chronic alveolar abscess from right upper molar. 

tissue. 



Note general thickening of 



Never incise through the skin, when it can be avoided. The abscess 
is usually much nearer the surface of the mucous membrane, and in 
addition to this, an external scar is likely to become adherent to the 
bone and result in a disfiguring deformity. After the cavity is opened 
and drained, it is packed lightly with gauze which serves to keep the 
wound open. This must be changed daily. In this type of abscess 
there is usually considerable fever and prostration. These symptoms 
rapidly disappear after operation, but as the cause of the infection has 
not been removed, the abscess is very likely to recure when the incision 
heals. Consequently, it is important to have the tooth either extracted 
or treated so as to prevent recurrence. Modern dentistry teaches that, 
if it is advisable to attempt to save the affected tooth, the root canal 
should be completely cleaned out and filled. It is usually found most 
convenient to have this dental work done after the acute reaction has 
subsided but before the sinus has entirely closed. 



142 INJURIES TO THE HEAD 

In the severest type of alveolar abscess, where there is osteomyelitis 
to a greater or less extent, the sinus persists and the abscess tends to 
recur even after the tooth has been extracted. This is because the 
stripping up of the periosteum has denuded the bone which soon dies, 
forming a sequestrum which must be discharged before healing can 
occur. In severe cases a large part of the body of the jaw may be 
enclosed in a thick envelope of new bone formed from the periosteum, 
and this large sequestrum must be discharged before healing is com- 
plete. If a roentgen ray shows a complete sequestrum, osteotomy 
should be performed and the dead bone removed. If this sequestrum 
does not appear on the roentgenograph, the dead bone is usually 
granular in form and will be discharged if the sinus is kept open. 
Where the process has been extensive, it may require months or years 
before healing is complete, and there is likely to be permanent 
thickening of the body of the mandible. 

Peritonsillar Abscess.— A collection of pus either in or around the 
tonsil causes very acute pain and marked systemic symptoms. In 
such cases the tonsil is pushed toward the midline instead of being 
enlarged symmetrically as in follicular tonsillitis. Most cases begin 
as an acute pharyngitis or tonsillitis, but occasionally a case is seen in 
which there is no apparent inflammation of the mucous membrane 
preceding the abscess. In the late stage, the tonsil and pharynx are 
markedly inflamed, and there is a diffuse indurated area which may 
show fluctuation at the center. 

Treatment.— Incision should not be attempted until there is evidence 
of a localized pus pocket. 

The operation may be done under gas or local anesthesia. If local 
anesthesia is used, the tonsils should first be swabbed with 4 per cent 
cocain, and the tissues then injected with 1 per cent novocain. As 
the ordinary hypodermic syringe is too short to inject the tonsils 
conveniently, a long needle or an extension shank should be used. The 
blade of a sharp-pointed scalpel, covered with adhesive plaster except 
about one-half of an inch at the top, is plunged into the abscess-cavity. 
This small opening is enlarged from without inward, or downward and 
inward, so as to avoid injury to the large vessels. The abscess-cavity 
is then irrigated with weak peroxide of hydrogen and this is repeated 
daily. Frequent throat irrigations with hot saline solution or bicar- 
bonate of soda solution (1 per cent) have a decidedly beneficial effect, 
especially upon the pain. In children small amounts of bicarbonate 
of soda may be placed upon the tongue and allowed to dissolve. 

It has been urged that peritonsillar abscesses heal much better when 
allowed to discharge spontaneously and that consequently they should 
not be opened. The basis for this recommendation seems to be due to 
the fact that many peritonsillar abscesses are not treated properly. 
Failure in such cases is due to: (1) Incising before the abscess has 
localized; (2) too small an incision, which heals rapidly allowing the 
abscess to reform; (3) not reaching the abscess-cavity; (4) multiple 
small abscesses. 



SEPTIC INFECTIONS OF THE FACE AND SCALP 143 

Retropharyngeal Abscess.— An abscess between the cervical vertebrae 
and the posterior pharyngeal wall is likely to occur in poorly nourished 
children, either as a result of tonsillitis or carious teeth or from some 
other infectious focus about the mouth. In chronic cases it may be 
tuberculous and is sometimes secondary to Pott's disease of the cervical 
spine. The abscess is usually subacute in character, rarely showing 
any surface or surrounding induration. The diagnosis is made upon 
the appearance of bulging in the posterior wall of the pharynx and 
fluctuation when the pharynx is palpated with the ringer. 

Treatment. — The child is wrapped in a sheet so that the arms may be 
controlled, is then placed upon a table so that the head extends over the 
edge, and is held by an assistant. A mouth-gag is inserted into the 
mouth, serving to retract the tongue and expose the posterior pharynx. 
The knife with the blade protected, as described above, is held in the 
right hand and passed down along the finger to the posterior wall of 
the pharynx and made to enter the abscess-cavity. This incision is 
enlarged in the midline and the child turned so that the pus can run out 
of the mouth. If desired, the operation can be performed under 
anesthesia, but a very light narcotic is all that is required. Indeed, 
a deep anesthesia is undesirable, because the child may aspirate some 
of the pus when the abscess is opened. Usually, no after-treatment is 
necessary, except attention to the general health. Irrigation may be 
attempted, but in children this is painful and very difficult and is not 
of sufficient importance to be insisted upon. 

In abscesses about the mouth it should be remembered that the 
patient is swallowing quantities of pus, so that it is wise to keep the 
bowels moving freely. A satisfactory laxative is heavy white mineral 
oil taken twice daily. 

In some cases, a retropharyngeal abscess tends to point externally, 
usually in the upper triangle of the neck. When the abscess is near the 
surface it may be incised externally, the pharyngeal incision being 
omitted. Lateral external incisions for the deeper abscesses are 
unjustified, because of the danger of injuring the large vessels of the 
neck. 

Suppurative Parotitis. — This infection of the salivary gland may 
be of systemic origin, as in pyemia, but it is usually caused by micro- 
organisms ascending the duct from a foul mouth. 

Trauma, such as a blow on the parotid region, or the lowered resist- 
ance following anesthesia, is often a deciding factor in suppurative 
parotitis. 

In its early stages septic parotitis is usually mistaken for mumps, 
and even in its later stage it may clear up by resolution or by discharg- 
ing thr ought the duct. 

Treatment. —Where a pocket of pus is formed in the gland, it should be 
treated the same as any other abscess, care being taken in making the 
incision to avoid the branches of the facial nerve. Drainage of the 
parotid frequently results in a salivary fistula. 



144 



INJURIES TO THE HEAD 



On the capsule of the parotid gland there are a number of lymphatic 
nodes, inflammation of which may secondarily involve the gland. 
Early drainage of these suppurating glands is, therefore, indicated. 

Erysipelas. — Erysipelas has been described in detail in another 
chapter, but it should be mentioned here because of its frequent 
and characteristic occurrence upon the face. It usually begins at the 
location of a slight scratch or abrasion upon the nose or cheek and 
spreads slowly across the cheek, forming a kind of butterfly-shaped 
area of inflammation, the inflammation on the nose forming the body 
and that on the cheeks representing the wings of the butterfly. The 
constitutional symptoms are marked and the inflammation generally 
slowly spreads over the cheeks and onto the forehead and scalp. This 
condition is associated with marked edema about the eyelids which 
may be sufficient to close the eyes completely. During the time the 
disease is confined to the nose it is rather difficult to differentiate the 




Fig. 63.— Abscess of the parotid 
gland. Duration, six days. 




Fig. 64. — Mumps. Duration, four 
days. 



condition from a boil, which on account of the attachment of the skin 
to the cartilage takes on the flat appearance of erysipelas. Often, 
only the course of the disease differentiates the two conditions. There 
are no special indications in the treatment of facial erysipelas. The 
disease is apparently more likely to be self-limited in facial erysipelas 
than in the same condition occurring elsewhere. 

Anthrax. — The lesion of anthrax (malignant pustule) is fairly com- 
upon the face. In addition to those cases occurring among workers 
in wool and hides, cases occur from accidental infection either from 
an infected shaving brush, or infected neck pieces of wool or fur. The 
lesion begins as the characteristic black ulcer which is surrounded by an 
area of edema out of all proportion to the size of the ulcer. Con- 
stitutional symptoms appear early and there is marked prostration. 
The treatment consists in early excision of the ulcer with the application 
of wet antiseptic dressings and the use of Sclavos serum, which has 
recently been developed by the Federal government. During the 



SEPTIC INFECTIONS OF THE FACE AND SCALP 145 

last two years the serum has been used alone (without excision of the 
lesion) at the Kings County Hospital, Brooklyn. Injections were 
made in the region of the lesion and favorable results have been 
reported. Even under the best treatment the death-rate is high. 

Actinomycosis. — Actinomycosis is a rare disease, especially liable 
to occur about the face and jaw. A common site is the region over the 
masseter muscle. The lesion usually appears as a hard area of indura- 
tion showing one or more sinuses from which there is a seropurulent 
discharge. This discharge contains small yellow granules which, when 
examined under the miser oscope, show characteristic ray fungus. 
The treatment consists of excision of the diseased tissue and the 
administration of potassium iodide both internally and as a wet 
dressing. Large doses of potassium iodide, up to an ounce or more 
daily, have been given with benefit in severe cases. If the disease has 
progressed to any extent, a cure is very difficult. 




Fig. 65. — Actinomycosis of neck of nine months' duration. 



Glanders. — Acute glanders is so rapid and is attended by such 
marked systemic symptoms that the patient rarely presents himself 
for treatment of the local lesion. On the other hand, the farcy type 
may be seen in minor surgical clinics. It is characterized by an intense, 
inflammatory reaction about the point of inoculation, with a strong 
reaction in the dependent lymphatic channels and nodes. The reaction 
consists of small swellings along the lymphatic channels known as 
" farcy buds," which rapidly form into abscesses. These break down 
into ulcers, discharging a gelatinous, hemorrhagic pus in which the 
Bacillus mallei may be found. 

Through the systemic infection, hard nodules may be formed in the 
various tissues of the body, but they are most easily observed in the 
subcuticular tissue and muscles, where they rapidly break down, 
simulating the appearance of tuberculous or gummatous ulcers. 

Treatment. — Early excision and wide drainage of the primary lesions, is 
called for with the application of wet, antiseptic dressings. Injections 
10 



146 



INJURIES TO THE HEAD 



of small doses of mallein, and general sustaining medical treatment for 
the systemic infection. 

Syphilis. — When the primary lesion of syphilis occurs on the face 
its commonest site is the lips, the secondary lesions occur upon the 
forehead and the temples, while the gummatous changes of the tertiary 
period occur frequently in the nose, the palate, and the frontal bone. 

Primary Lesion.— A chancre may occur on the tongue, the lips or the 
mucous membrane of the mouth. As infection may occur from kissing 
a syphilitic or from drinking from an infected glass or from smoking 
an infected pipe, the history is of little value. A recent case of chancre 
of the gum, the result of a scratch made by an infected dental burr, 
illustrates the possibility of the transmission of the disease by careless 
dentists. Cases presenting chancres of the cheek as the result of a 
bite are not uncommon. It would seem that the direct inoculation 
from the bite of a syphilitic is especially dangerous. However, any 
small scratch may serve as a portal of infection. 




Fig. 66. — Chancre of the lip. Duration, two months. 

Occurring on the lips, the lesion has the characteristic appearance of 
a chancre on the penis, showing the indurated base and sluggish surface 
of the ulcer ; but when it appears on the cheek, it is likely to resemble 
more the epitheliomatous ulcers which occur on the face. The indura- 
tion may be marked and there may be slight swelling of the lymph 
nodes. When untreated, healing usually takes place in about two 
months, a smooth, whitish scar resulting. Spirochsetse may be found 
in the discharge. 1 It must be remembered that the Wassermann 
reaction is always negative in these primary lesions and is, consequently, 
of no diagnostic value. 

Treatment.— If seen early, the excision of the chancre is advisable. 
This will not prevent the occurrence of constitutional syphilis, but it 
removes one focus of the disease, and this may limit the degree of 

1 In three cases of our series it was impossible to demonstrate the spirochetal in the 
initial ulcer on the lips. Aspiration of the enlarged cervical glands showed the organism 
in large numbers. 



SEPTIC INFECTIONS OF THE FACE AND SCALP 



147 



infection. If the ulcer already shows considerable development, it 
should be treated with a wet bichloride of mercury dressing or a 10 
per cent ointment of ammoniated mercury. Blue ointment, because 
of its color, is rarely advisable. Patients invariably object to it and 
either omit it or apply it very lightly. The general treatment is the 
same as for a genital chancre. 

Secondary Lesions. —The eruption of the secondary stage of syphilis 
may occur on the face, especially about the hair line, or in the form of 
mucous patches of the tongue or throat. Local treatment has little 
or no influence on these lesions. Occasionally there is an associated 
infection of the cervical lymph nodes which may require operation. 
Cleanliness of the mouth tends to relieve the severity of the mucous 
patches. The main reliance should be placed in the antisyphilitic 
constitutional treatment. 

Tertiary Lesions.— Ulceration of the palate, of the nasal septum, or 
of the frontal bone is always suggestive of tertiary syphilis, and this 
is particularly true when the ulceration 
extends deeply, involving the bone. 
Gumma of the forehead, which is par- 
ticularly characteristic, has received the 
name of corona veneris because of its 
frequent occurrence and its diagnostic 
significance. It begins as a hard swell- 
ing a little larger than a silver quarter, 
gradually becomes softer, and finally 
breaks down exposing a necrotic seques- 
trum roughly circular in outline. 

Treatment.— The treatment of gum- 
mata of the nose and palate is limited 
to general measures for the cure of 
syphilis. In gummata of the frontal 
bone the same treatment is indicated. 

After the skin has broken additional treatment should be directed 
toward the prevention of mixed infection, which owing to the proximity 
of the dura may lead to septic meningitis. If healing is delayed 
because of the sequestrum, its removal is indicated. Usually it will 
discharge spontaneously, but occasionally it persists so long that it is 
necessary to remove it by operation. Two different possibilities may 
exist. Either the outer table alone is involved, or the entire thickness 
through to the dura. When the outer table alone is affected, the 
bone can be chipped away with a sharp chisel; but when the entire 
thickness must be removed, it is an operation which requires trephin- 
ing and exposure of the dura. After operation the wound should be 
closed by a plastic operation on the scalp. 

The treatment during the stage of ulceration is important. In 
addition to the general treatment, the ulcer should be kept clean and 
as nearly free from mixed infection as possible. While local treatment 




Fig. 67. — Scar of gumma 
of forehead. 



148 



INJURIES TO THE HEAD 



with mercurials has little or no effect if general remedies are not used, 
yet it would seem that the combined use of mercury both locally and 
generally seems to have a beneficial effect. This is denied by some 
writers, who claim that the ulcer heals just as rapidly under any form 
of antiseptic dressing as when mercury is used. Be this as it may, it 
certainly appears rational to dress the wound with a mercurial anti- 
septic, such as ammoniated mercury ointment, to prevent mixed 
infection. The general treatment with arsphenamine, or one of the 
other arsenic preparations, should, of course, be insisted upon. 

Tuberculosis. — Tuberculosis of the face occurs in the form of lupus 
vulgaris and tuberculous ulcers of the lips, nose and mucous membrane 
of the mouth. Tuberculous ulcer of the nose rarely occurs as a primary 
lesion, the infection being secondary to lupus or tuberculosis of the 
lungs. Tuberculosis of the lips and mouth is practically always 
secondary to pulmonary disease. 




Fig. 68. — Tuberculosis of the scalp, following operation for subperiosteal cyst. 

ently a surgical infection. 



Appar- 



Lupus Vulgaris.— This disease is ordinarily limited to the skin. It 
begins as one or two pinkish nodules in the skin near the nose, and 
gradually spreads involving the nose and cheeks. It is likely to spread 
out in the butterfly form, somewhat resembling lupus erythematous 
and erysipelas. It can be distinguished from the former by the 
presence of papules, tubercles, and ulceration, and from the latter by 
the marked chronicity of its course. Except in its location, it has little 
resemblance to erysipelas and should not be confused with it. 

As the patches develop, the nodules ulcerate, forming shallow 
excavations. There is a purulent secretion which is likely to be rather 
scanty in amount and which leads to crust formation. This is later 
followed by healing with tough fibrous scars which contract and may 



SEPTIC INFECTIONS OF THE FACE AND SCALP 



149 



cause marked deformity of the mouth, nose, or eyelids. The disease 
slowly progresses, so that the usual case is of several years' duration 
and shows all stages of development from the pinkish or brownish-red 
nodule to the firm scars of complete healing. It may extend to the 
neck and body or it may remain fairly localized in the region of the 
nose. Invasion of the scalp is rare. The cases are likely to be seen in 
well-developed and well-nourished individuals, tuberculosis of the 
lungs being comparatively rare. 

Treatment. — Careful attention should be given to hygienic measures 
aimed to increase the resistance of the patient. Cod-liver oil, given 
for a long period, and other tonics seem to have a beneficial influence. 
The syrup of the iodide of iron has been highly recommended, and lately 
thyroid extract has been used with marked benefit in cases in which 
the inflammatory element was prominent. 





Fig. 69. — Tuberculosis of the nose. 
Duration, four years. 



Fig. 70. — Primary tuberculosis of the lower 
jaw. First symptom, loosening of the teeth. 
Extensive excision of bone, followed by roent- 
gen-ray treatment and cure. 



The local treatment should be complete excision, if the diagnosis is 
made before the lesion has become extensive. Often the diagnosis 
is not made until the condition has become too extensive for operation 
and other methods must be utilized for its control. The ultra-violet 
ray and the roentgen ray have both given satisfactory results in certain 
cases without, however, being curative in all stages of the disease. 

Dermatologists recommend the application of strong ointments, 
some of which are actually destructive. Salicylic acid collodion (30 
to 60 grains to the ounce) is one of the milder applications, while lactic 
acid is one of the stronger. Lactic acid is applied on gauze for ten to 
twenty minutes daily, the surface being covered during the interim 
with a mild ointment. This usually causes destruction of the lesion. 

Curettage and multiple parallel incisions of the surface of the lesion 
have both been practised with variable results. In obstinate cases 
their trial is justified. For cases showing ulceration, a mild antiseptic 
ointment or wash tends to prevent the development of mixed infection. 

Tuberculin treatment should have a thorough trial in every case. 
The various types of tuberculin act in much the same manner, and all 



150 



INJURIES TO THE HEAD 



have much the same effects. The bacillary emulsion (B.E.) has 
appeared to us to give better results than some of the other prepara- 
tions. The dosage is the same as in other forms of surgical tuberculosis. 

Tuberculous Ulcer.— A single ulcer of the nose, either alone or com- 
bined with lupus, may occur and is likely to be confused with syphilis 
or epithelioma. It differs from syphilis in that it practically never 
invades the cartilages of the nose. Its differentiation from epithe- 
lioma is difficult, often requiring microscopic examination of an 
excised segment to make the diagnosis certain. Tuberculous ulcer of 
the lips or mucous membrane of the mouth occurs in individuals 
suffering from advanced pulmonary tuberculosis. 

If possible, a tuberculous ulcer should be excised; but if it is too large 
for excision, local treatment by caustics or roentgen ray may be tried. 
This is usually unsuccessful unless the disease in the lungs is arrested. 



BENIGN TUMORS OF THE HEAD. 

Moles. — Moles are small tumors of the skin occurring frequently 
on the face and neck. 

These tumors require removal, not only because they are disfiguring 
but also because they undergo malignant degeneration. 

Treatment.— Excision is the method 
of choice. A small mole may be snipped 
away with a pair of sharp-pointed 
scissors without removing the entire 
thickness of the skin. The area is 
first anesthetized with 0.5 per cent 
novocain solution and the mole picked 
up with a pair of fine-toothed forceps 
and then cut away with scissors or a 
sharp knife. If dressed aseptically, 
the wound heals without appreciable 
scar formation. 

In the removal of large moles, the 
entire thickness of the skin must be 
removed. An elliptical incision is 
made surrounding the mole at the 
widest part, and the entire thickness of the skin is dissected away. 
The edges of the skin are now sutured with fine silk or horsehair, the 
edges being undermined for a short distance if there is much tension. 
If desired Michel skin clips or a subcuticular catgut suture may be used. 
When sutures are used on the face, it is well to remove them on the 
fourth day unless it is evident that this will cause gaping of the wound. 
Moles and other small tumors may be removed by freezing with 
carbon-dioxide snow. The carbon dioxide pencil is applied with 
moderate pressure for from one to two minutes after the skin has been 
made surgically clean. After the application, the area should be 




Fig. 71. — Small pigmented mole of 
ear, present since birth. 



BENIGN TUMORS OF THE HEAD 



151 



covered with a light dressing to prevent infection. The scar which 
follows is soft and shows very little tendency to contraction. There 
is very little pain associated with this operation. 

Electrolysis is another method used in the removal of small tumors. 
This is rather painful and may require local anesthesia. The current 
may be applied by a battery of chemical cells or by an electric light 
current reduced to a low voltage. About 3 to 10 milliamperes is 
sufficient. 1 There are two electrodes, a sponge which is wet and placed 
firmly on the skin near the tumor, and a needle electrode which is 
pushed into the tumor near its edge and left in place from ten to fifteen 
seconds. If the current is the proper strength, the skin will become 
blanched in the vicinity of the needle. There is usually very little 
hemorrhage. Several such punctures about one-eighth of an inch apart 
are made at each sitting. Treatment should be given about once a 
week. A certain amount of cicatrization results. 

Cauterization by chemicals, such as nitric acid and monochloracetic 
acid, may be tried. They are usually inadvisable except in selected 
cases, because the irritation may lead to malignant degeneration. 

Papillomata or Warts. — Papillomata or warts may occur upon the 
face, but less frequently than on the hands. They are treated in the 
same manner as moles. 




Fig. 72. — Large congenital angioma of the ear. Cured by excision. 

Angioma. — Angiomata are very common upon the face and scalp. 
They occur frequently in children and sometimes grow very rapidly. 
There are two common forms, the capillary angiomata, or nevi (port 
wine marks), and cavernous angiomata which are likely to extend 
deeply into the subcutaneous tissues. 

Treatment.— The same methods that are used in the treatment of 
moles are applicable to the treatment of angiomata. The method 
used depends considerably upon the size and location of the angioma. 

1 A rough test of the current may be made by plunging both the needle and the sponge 
into a 5 per cent solution of sodium chloride. The current is then slowly turned on and 
when fine bubbles begin to rise from the needle, the proper strength has been reached. 



152 



INJURIES TO THE HEAD 



Excision is of value only in small or pedunculated angiomata. In 
the excision of the growth the operator should be prepared to encounter 
considerable hemorrhage, which is usually easily controlled. If the 
incision is carried around the tumor and not through it, the bleeding 
will be slight. 

In capillary angiomata, carbon-dioxide snow is preferable. It is 
applied in the same manner as in the treatment of moles. It should be 
pressed against the area with pressure enough to blanch the part for 
from thirty to ninety seconds. It can also be used in the superficial 
type of cavernous angiomata, but it is unsatisfactory when the tumor is 
covered with a thick layer of skin. 

The galvanopuncture (electrolysis) is of even greater value in the 
treatment of angiomata than it is in the case of moles. Hemorrhage is 
sometimes troublesome. In these cases it is well to begin the puncture 
through the normal skin at the edge of the growth. 

The injection of boiling water is another method which may be tried 
in the larger angiomata. A syringe with a capacity of about 10 cc is 
filled with sterile water and boiled for a few minutes so that the syringe 
and its contents are both heated to the temperature of boiling water. 
The syringe is then held in a towel and a few cc of boiling water are 
injected into the tumor. This operation is associated with a certain 
amount of danger, for it may cause embolism. It is not advised unless 
other methods have resulted in failure. 

Sebaceous Cysts. — These cysts are very 
common on the scalp and face. On one 
occasion we removed from the face and 
scalp, at a single sitting fourteen varying 
from the size of a pea to that of a walnut. 
They may attain considerable size, grow- 
ing as large as an orange or even larger. 
The contents consist of sebaceous mate- 
rial, but when infection occurs, it becomes 
mixed with pus. Sebaceous cysts of the 
scalp are commonly called wens. 

Diagnosis.— The diagnosis is made on 
the history of chronicity, their attachment 
to the skin, and the finding of the opening 
of the duct which can often be seen near 
the center of the cyst and which can 
sometimes be made to discharge sebaceous 
material by firm pressure upon the tumor. When they become in- 
fected, they resemble a furuncle in appearance, but can usually be dis- 
tinguished by careful examination. If they are mistakenly incised for 
a boil, the character of the discharge, which is always sebaceous in 
character, serves to differentiate the two conditions. 

Treatment of Uncomplicated Cyst.— In the smaller cysts, a straight 
incision is made and the small spherical mass is shelled out by blunt 




Fig. 73. — Sebaceous cyst at 
outer angle of the eye. Infected. 



BENIGN TUMORS OF THE HEAD 153 

dissection. In the larger cysts, an elliptical incision should be made 
over the cyst and gradually deepened until the cyst-wall comes into 
view. Novocain, 0.5 per cent, is ordinarily used for anesthesia. When 
the shiny cyst-wall is fully exposed, careful dissection, most of it blunt 




Fig. 74. — Group of old, broken-down sebaceous cysts of scalp undergoing epithelioma- 
tous change. Very offensive odor. Wide excision. Cure. 

dissection, will remove the cyst entire. A frequent source of difficulty 
is caused by the attempt at enucleation before the last layer of con- 
nective tissue has been incised. This is overcome by dissecting care- 




Fig. 75. — Same case as that shown in Fig. 74 showing final result. No skin-grafting. 
Bare bone slowly covered by granulations, followed by healing. 

fully with blunt-pointed scissors until the sac is reached, the layers of 
connective tissue being caught up in a pair of forceps and cut through 
one by one until the shiny, white wall of the sac appears. Dissection 
is carried on carefullv around the tumor, either with the closed end of 



154 injuries to the head 

the scissors or by inserting the scissors closed and then opening them in 
the tissues. Only rarely will a strip of connective tissue require 
division. In some cases the sac may be accidentally opened, allowing 
some of the contents to escape. When this occurs, an artery clamp 
may be clamped over the opening, preventing the further escape of the 
contents. If the sac is torn in the removal, care should be taken to 
remove every particle of the inner surface of the cyst, or recurrence will 
surely result. After the cyst has been removed, the bleeding points 
are ligated and the wound sutured. Pressure upon the wound by 
means of a pad of gauze serves to obliterate the cavity left after the 
removal of the cyst. If the space is large and pressure will not suffice 
to close it, the sides of the cavity may conveniently be brought together 
by means of buried catgut sutures. The skin may be sutured with 
horsehair or a subcuticular catgut suture, and a dry sterile dressing 
applied. After the second or third day, wounds of the face may be left 
exposed and dusted with a little powder, such as aristol or nosophen. 
If the dry blood at the edge of the wound is not disturbed, it acts as the 
best sort of protection. 

In the case of large cysts upon the face where it is desired to 
avoid a large scar it is sometimes advisable to make a preliminary 
incision and to express the contents, after which the wound is 
allowed to heal. The cyst will recur but it will be only a fraction of 
its former size and may be removed through a small incision. Another 
method of avoiding a large incision on the face is to expose the wall 
of the sac by a small incision and then to puncture the sac and express 
the contents. The wall of the sac at the point of puncture is then 
grasped in an artery clamp and the artery clamr> is twisted so as to 
wrap the cyst wall upon itself. At the same time the attempt is made 
to free the cyst by blunt dissection. In some cases the twisted cyst 
may be drawn out through a very small opening. The disadvantage 
of this latter method is that the cyst may be torn and a portion of the 
wall left to cause recurrence later. 

Treatment of Adherent and Infected Cysts.— Cysts which have become 
inflamed may be surrounded by an area of induration and resemble 
a boil, or the infection may be chronic and show only as a reddened 
shiny surface with adhesion of the sac to the skin and fascia. In these 
cases an elliptical incision is made, the skin of the ellipse being left 
attached to the tumor. As the tumor is likely to be adherent through- 
out, it must be dissected out by sharp dissection, care being taken to 
keep close to the cyst-wall. If the contents are not allowed to escape 
and the infection is not active beyond the walls of the cyst, the cavity 
may be closed and the skin sutured in the same manner as in an uncom- 
plicated case. 

Cysts are occasionally seen as the seat of very acute inflammation. 
They should be incised and drained, the inner surface being well 
swabbed with carbolic acid. A few cases treated in this manner do not 
recur, but it should be explained to the patient that the cyst is likely 



BENIGN TUMORS OF THE HEAD 



155 



to recur after the wound has healed, in which case a second operation 
will be required. It is well to wait until a definite tumor is present 
before operating. In secondary operation for recurrent cyst, the wall 
is usually adherent throughout. 

Dermoid Cyst. — Dermoid cysts are common about the face and 
scalp. They occur along the line of embryonic fissures and are sup- 







'^| 






P 




4^a 




HHHHHIHh 







Fig. 76. — Small dermoid at outer angle of the eye. 

posedly present at birth. They are often not apparent until adult 
life, so that if they are present at birth they must be very small, only 
becoming noticeable as they grow larger in later life. In some cases 
they remain quiescent for years, showing no increase in size; while in 
others they slowly increase, frequently becoming as large as an egg 




Fig. 77. — Large dermoid behind the ear. Noticed for two years. 



and occasionally much larger. They may require removal, either 
because of the disfigurement or because they become infected. They 
are not attached to the skin, but are usually attached to the deeper 
parts, in some cases being attached to, and causing a depression in, the 
skull. 

The midline of the face and scalp, the regions about the angles of the 



156 INJURIES TO THE HEAD 

eyes and about the ear, are the sites where dermoids are likely to occur. 
The mere presence of a tumor in any of these locations should suggest 
dermoid cyst. Occasionally they undergo malignant degeneration. 

Diagnosis.— It is sometimes exceedingly difficult to differentiate 
dermoid cysts and sebaceous cysts. The sebaceous cyst is attached 
to the skin but movable in the deeper parts, showing a duct orifice at its 
center from which sebaceous material can be pressed, and is rare during 
childhood. A dermoid is attached to the deeper parts at its base, the 
skin is movable over it, it has no duct orifice, and occurs at any age. 
Dermoid cysts are not uncommon over the region of the parotid gland 
and usually penetrate deeply between the branches of the facial nerve. 
They are sometimes shaped like a collar-button with a small superficial 




Fig. 78. — Cyst of inferior maxilla; opened; lining membrane removed and cavity packed; 

healing prompt and permanent. 

sac and a small tract connecting a large, deep sac. The latter is usually 
sub mucoid in character. Such cysts are usually very difficult to cure 
even after several operations. Persistent sinus after operation is not 
uncommon. 

During removal the attachment at the base is easily distinguishable 
in the case of a dermoid; and the contents, although largely sebaceous, 
occasionally contain hairs. 

Treatment. —The preliminary incision for the removal of dermoids 
is the same as for sebaceous cysts, but owing to the attachment of the 
base of the cyst to the bone, it is sometimes advisable to give a general 
anesthetic instead of depending wholly upon local anesthesia. As a 
general rule in surgery, operations involving bone and periosteum are 
often easier under general anesthesia. 



CYSTS AND CALCULI OF THE MOUTH 157 

When the dissection of the base is difficult, it is sometimes desirable 
to open the sac so that the prolongations may be seen and dissected 
free. In a few cases a prolongation of the sac has been seen to enter 
the cranial cavity. In such cases as much of the sac is removed as is 
possible and the remainder cauterized with pure carbolic acid. 

After the complete removal of the sac the wound is closed in the 
same manner as after the removal of a sebaceous cyst. If a small 
portion of the periosteum has been removed, it requires no special 
treatment as there is no danger of necrosis unless there is suppuration. 

If a dermoid cyst is suppurating and the surrounding tissues are 
inflamed, it is better simply to incise it at once and remove the sac at a 
later date. Sometimes the simple incision, with the application of 
pure carbolic acid swabbed over the entire inner wall of the sac will 
cause complete obliteration. This procedure is so inferior to excision, 
however, that it is only justified when infection is present. 

In order to avoid a large scar on the face, it is sometimes better to 
make a preliminary incision with expression of the contents of the sac 
as outlined under sebaceous cysts. 

Congenital Sinus. — Closely related to dermoid cysts are the congen- 
ital sinuses of the pharyngeal clefts, the first of which terminates 
just in front of the ear. When the sinus occurs it may be little more 
than a dimple or it may pass inward several inches. Occasionally 
there is a sac at the inner end of the sinus. The lining is formed by 
epithelium, and consequently a sinus frequently exists for a long time 
without giving rise to symptoms. Sooner or later it is almost certain 
to become clogged up and the normal secretion of the skin fills up the 
cavity, forming a cyst; or else it is the seat of irritation and infection, 
with an accompanying purulent discharge. 

Treatment. —The only treatment worthy of trial is the complete 
excision of the sinus. If any of the epithelial lining of the sinus is 
allowed to remain, it is likely to develop slowly into a cyst. Owing 
to the thickness of the skin, cauterization with carbolic acid will not 
destroy the lining membrane. 



CYSTS AND CALCULI OF THE MOUTH. 

Mucous Cysts. — Obstruction of the duct of a mucous gland in the 
mouth results in the formation of a cyst. The cyst is thin-walled, 
transparent, and rarely larger than a pea. When it is incised, a small 
quantity of clear mucous is poured out. The treatment consists of 
snipping the wall with a pair of scissors and swabbing the cyst with 
tincture of iodine. No anesthesia is required. Recurrence is uncom- 
mon. 

Ranula. — When a duct of the sublingual, or submaxillary, salivary 
glands becomes stopped, the secretion continues with the result that the 
swollen duct may be seen, dilated and tortuous. This is called a ranula, 



158 



INJURIES TO THE HEAD 



If the condition is untreated, the dilation continues until a large ovoid 
cyst with clear viscid contents, is formed. 

Treatment.— In early cases where the ranula consists only of the 
slightly dilated duct appearing like a tortuous vessel beneath the 
mucous membrane, simple incision is all that is required, the pressure 
of the saliva usually serving to keep the wound open. Occasionally 
the incision closes and must be reopened. 

In the larger cysts it is often necessary to remove a portion of the 
cyst-wall. 





Fig. 79. — Mucous cyst of lip, 
growing in a four year old scar. 



Fig. 80. — Ranula, recurrent. Two 
months since former operation. 



Parotid Cyst. — A retention cyst of the parotid gland is a rare con- 
dition. Excision is the only treatment which has proved satisfactory. 
During the operation, extreme care should be used not to injure the 
branches of the facial nerve. After removal, the wound should be 
sutured. A small salivary fistula is a frequent complication. It 
heals by granulation within a few weeks. 

Salivary Calculi. — Closely related to the cysts of the salivary glands, 
and occasionally associated with them, are the calculi which occur 
either in the gland substance or along the ducts. They occur most 
frequently in the submaxillary gland, but they may occur in the paro- 
tid. They can be felt as hard lumps, usually along the course of the 
duct. In the gland substance, they cause few symptoms, and unless 
very large do not require removal; but in the duct, they cause obstruc- 
tion and irritation which lead to dilation of the duct and occasionally 
to suppuration. 

Treatment.— A calculus impacted in the mouth of the duct can be 
removed by direct incision through the mucous membrane of the 
mouth. Pressure is made externally with the finger, and under local 
anesthesia the stone is exposed by an incision parallel to the course of 
the duct. No sutures are necessary because, although a fistula may 
form, it is of no consequence when it discharges into the mouth. No 
matter how close to the skin the stone appears to lie, the incision should 



BENIGN TUMORS OF THE FACE 159 

never be made externally, for the result will be a troublesome salivary 
fistula. 

Salivary Fistula. — Due to either accidental or operative wounds, 
or occasionally to the rupture of an abscess secondary to the calculus 
of the duct, a sinus may be formed between the duct of the salivary 
gland and the external surface. If the salivary fistula is over the 
gland, it tends to close rapidly if touched occasionally with pure car- 
bolic acid or silver nitrate; but a fistula connecting with Stenson's 
duct is said to persist indefinitely, unless closed by operation. 

Treatment.— There are two points which must be accomplished by 
any plan of treatment : the stream of saliva must be made to pass into 
the mouth, and the opening in the skin must be closed. 

If the probe can be inserted in the distal portion of the duct it should 
be well dilated and slit so as to make the mouth of the duct widely 
open. The edges of the fistula in the skin are cut away and the wound 
is sutured. This will sometimes be all that is required. 

In most cases it is impossible to pass a probe into the duct, or even 
when it is accomplished the saliva continues to be excreted externally 
through the fistula. 

A method which is usually successful consists of enlarging the opening 
on the cheek so that the underlying duct is exposed. A trocar is now 
passed through the wall of the duct into the mouth and a small fenes- 
trated rubber tube is inserted through this opening, the inner end being 
cut off level with the mucous membrane and the outer end lying at the 
external opening of the fistula. The tube is held in position by a silk 
thread passed through the tube and tied externally. This is left in 
place for about four days. It is then slipped slightly inward so that 
the outer end lies at the bottom of the fistula, and the inner end is cut 
off level with the mucous membrane and held in place by one suture 
placed in the mouth. The mouth of the fistula is then pared and 
sutured. The drainage tube must be kept in place until there is firm 
union of the skin, which requires about ten days. 

Another plan of treatment is to dissect out the duct proximally to 
the fistula and to insert the end through the mucous membrane of the 
mouth, posterior to the original opening. The fistula is then easily 
cured by paring the edges and bringing them together. This plan is 
often not practical because of the short length of the proximal portion 
of the duct. 

BENIGN TUMORS OF THE FACE. 

Lipoma. — Lipoma are slow-growing fatty tumors containing a few 
fibrous trabecular and surrounded by a poorly-defined capsule. They 
sometimes occur on the face, most frequently in the region of the 
forehead. They may be mistaken for dermoid or sebaceous cysts. 
Lipomata are more likely to be tabulated than are either variety of cyst. 
Unless they cause inconvenience from their size or are disfiguring, it 
is unnecessary to remove them. If operation is not desired, no internal 



160 



INJURIES TO THE HEAD 



treatment or external application will have any influence upon their 

growth. Occasionally lipomata are said to disappear spontaneously. 

Treatment.— As lipomata of the face are usually of the encapsulated 

variety, in contradistinction to the diffuse form which occurs generally 

on the neck or trunk, they are easily re- 
moved. An incision is made down to the 
fatty capsule, and pressure is then made 
with the thumb and finger so as to force 
the lipoma toward the wound. This will 
make the attachments of the capsule plain 
and the growth can be shelled out of the 
capsule. There are sometimes lobules 
extending from the sides which must be 
removed with the original growth or they 
will continue to grow. The capsule is not 
removed, as it does not tend to cause a 
recurrence. The walls should be approx- 
imated with catgut sutures, and the skin 
sutured with horsehair or fine silk. 
Osteoma. — A form of benign tumor forming an outgrowth from the 
bone (exostosis) and consisting of normal appearing bone is known as 
osteoma. Two forms are described: A hard non-cancellous form, 
known as an ivory exostosis; and a more diffuse osteoma, which is 
largely made up of cancellous bone. It is not uncommon on the skull, 




Fig. 81. — Submucous lipoma of 
lip of ten years' duration.} j 




Fig. 82. — Small osteoma of the forehead. 



and is occasionally seen on the bones of the face. On examination it is 
recognized by its hardness and by the fact that it is attached to the 
bone. 

Treatment. —When the tumor is small and does not cause deformity, 
it may be safely left, as malignant degeneration rarely, if ever, occurs. 



BENIGN TUMORS OF THE FACE 



161 



As osteoma about the skull and bones of the face is usually the ivory 
type of exostosis, it is often quite difficult to remove it. It is advisable 
to perform the operation under general anesthesia, as local anesthesia 
of the bones of the face is unsatisfactory. After the incision has been 
made, the osteoma is chiseled away, together with the overlying 
periosteum. The wound is then closed without drainage. 

When the osteoma is well-localized, it is sometimes possible to 
undermine the base with a dental burr and break off the tumor. This 
method is especially valuable in a tumor of the lower jaw where chisel- 
ing may cause fracture. 




Fig. 83. —Osteosarcoma of skull. Pathological report on first operation: Exostosis. 
Third operation showed invasion of brain, and diagnosis of sarcoma was made. Duration 
from time first noticed to death, sixteen months. Patient developed complete blindness. 

Fibroma. — Fibromata occur in two forms: The soft fibroma which 
is frequently seen in the skin, where it is called molluscum fibrosum; 
and the hard fibroma, which may occur any place where there is dense, 
firm connective tissue, as the fascia, nerves, periosteum, etc. They 
may undergo malignant degeneration or they may become cystic, 
calcified, or necrotic. After removal they have little tendency to recur. 

Treatment.— The soft molluscum fibrosum may be snipped off with 
scissors, leaving a small scar. A hard fibroma may be shelled out, when 
it has a capsule. More often it must be dissected away from the 
connective tissue attachment (fascia, etc.). The vessels in the center 
of the hard fibroma are attached to the fibrous tissues and do not 
contract when cut. Consequently, when a fibroma is cut across, there 
is likely to be a profuse hemorrhage which is almost uncontrollable. 
If this occurs, the remainder of the tumor should be excised as soon as 
possible, so as to cut through the vessels at a point where they are 
normal and will collapse. 

.Cutaneous Horn. — This is a horny growth from the skin, arising 
usually from the stratum mucosum and varying considerably in size 
and shape. It shows a preference for the face and scalp, but may be 
11 



162 



INJURIES TO THE HEAD 



found on any portion of the body. It differs from animal horns in 
that it does not contain bone and has a cutaneous rather than a bony 
attachment. 

It may be classified as a papilloma, in fact it is a papilloma which 
hyperkeratosis has changed to a horny substance. It may be knocked 
off accidentally, but usually recurs. Malignant degeneration of the 
base is not uncommon. 

Treatment.— The growth may be excised at its base together with the 
skin, but usually this causes considerable loss of tissue. 

A better plan is forcibly to break off the horn at its base. Usually 
this is easily accomplished, but occasionally it is necessary to dissect 
the growth away. After removal, the surface shows a pinkish area of 
epidermis, in the center of which are many bleeding papilla?. If the 
disease is not treated further, the growth will almost certainly recur, 
so that treatment must be directed toward the destruction of the base. 
This can be accomplished by the application of caustic potash, either 
in stick or strong solution (50 per cent). The application should be 
made for not over two or three minutes and the excess then washed 

away. A dark brown scab is formed, 
which drops off after five or six days. 
Usually no dressing is required. 

Other methods of removing the 
base are galvanocautery, curetting 
with a sharp spoon, and the use of 
nitric acid or other caustics. 

Myxoma. — Myxomata occur usually 
in the region of the salivary glands. 
Pure myxomata are encapsulated and 
when removed do not tend to recur. 
In the region of the parotid gland 
they must be differentiated from 
malignant growths of the parotid. In 
many cases tumors in the neighbor- 
hood of the parotid gland are mixed in 
character, partially malignant and 
partially myxomatous. As it is possible that these growths begin as 
myxomata and then undergo malignant degeneration, every tumor of 
the parotid region should be removed at the earliest opportunity. 
If malignant characteristics have not appeared, simple excision is 
usually considered sufficient. 




Fig. 84. — Carcinoma starting in a 
myxomata of long standing. 



MALIGNANT TUMORS OF THE HEAD AND FACE. 

Malignant tumors of the scalp are comparatively rare. When they 
occur, they usually result from degeneration of a previously benign 
growth. On the other hand, malignant growths of the face, lips, 
tongue, and mucous membrane of the mouth are very common. 



MALIGNANT TUMORS OF THE HEAD AND FACE 



163 



Epithelioma of the cheek is probably seen more frequently than any 
other malignant growth. 

Epithelioma. — Epithelioma of the face may begin without apparent 
cause from previously unbroken skin, or it may occur at a point where 
the skin has been subjected to chronic irri- 
tation, or it may begin as the so-called 
degenerative change of a mole or wart or 
other benign growth which has remained 
quiescent for years. Epitheliomata are 
common in patients over forty-five years 
of age and very rare in those under 
thirty. They occur rather frequently 
along the muco- cutaneous junctions, es- 
pecially about the nose and mouth. 

Superficial Epithelioma.— This is a par- 
ticularly slow growing type of cancer. It 
usually occurs in the cheek or nose often 
close to the eye. The patient first notices 
scaliness of a particular spot, which at 
times appears a little elevated and red- 
dened. This w^ill disappear for a time, 
and finally recur a little larger than before. 
After a variable period (often several months or longer), the patient 
notices a small ulcer with raised edges. This crusts over, and the 
patient is satisfied that healing is complete, only to have the crust 
fall off and the ulcer again become evident. When the case is first 




Fig. 85.— Angiosarcoma of the 
orbit of three years' duration. 




Fig. 86. — Small epithelioma of inner angle of eye in a woman, aged seventy-six years. 

Slow growth of two years' duration. 



seen by the surgeon, there is usually a small ulcer, from which there 
is a slight serous or serosaguineous discharge, which forms a crust. 
The edges are slightly elevated and have a pearly apearance, which 
is characteristic of this type of epithelioma. The growth is extremely 
slow. It is not unusual to see an epithelioma of this type, which has 
been growing for five years or even longer, no larger than a silver ten- 
cent piece. 



16i 



INJURIES TO THE HEAD 



The name rodent nicer has been given to the particular variety of 
superficial epithelioma in which the ulceration is marked and the 
element of new growth is very slight. There is very little infiltration 
of the border, even when the disease has progressed to a considerable 
extent. The edge advances steadily although very slowly. The 
lymph nodes are rarely involved until very late. 

Treatment.— For the early cases of epithelioma, any treatment which 
removes the growth will act as a permanent cure. Dermatologists 
who see many of the early cases often remove the growth by the 
application of caustics. A satisfactory practice in the early cases is to 
curette the growth thoroughly down into the deeper layer of the skin 
(the growth is soft and comes away easily under the curette, the healthy 
skin having a distinctly firmer feel), and to follow this by the applica- 
tion of a caustic-potash stick for a minute or two. The caustic should 
be removed after one or tw T o minutes by a large amount of water, or, 
better, neutralized with dilute acetic acid. The result is a dark brown 
or black crust which falls off after about a week, leaving only a slight 
amount of scarring. The larger varieties of epithelioma, the size of a 
dime or larger, should be excised. 





Fig. 87. — Rapidly growing epithe- 
lioma of the face. Duration, about 
five months. 



Fig. 88. — Extensive papilloma of the lip 
and inner side of the cheek of six years' dura- 
tion. Malignancy not proved; blood nega- 
tive. Successfully removed. 



Deep-seated Epithelioma.— This may begin as a superficial epithe- 
lioma or it may begin as a small nodules or tubercle in the skin. It 
slowly increases in size and after a few months shows ulceration 
externally. The ulceration shows a reddened base and there is a sero- 
purulent discharge. Growth is relatively rapid, the deep growth 
preceding the ulceration. The ulcerated area is somewhat raised 
above the skin and the edges may be slightly undermined. Usually 
the ulcer bleeds readily, a considerable hemorrhage sometimes following 
a slight knock. This type is likely to be very tender and to be associ- 
ated with neuralgic or burning pains, and the lymph nodes are likely 
to be involved fairly early. 



MALIGNANT TUMORS OF THE HEAD AND FACE 



165 



Treatment.— The treatment in the early stage is complete and wide 
excision of the growth. Thus a small growth, the circumference of a 
dime, should be excised with at least half an inch of normal skin on the 
sides and the excision should remove all the fat to the deep fascia. 

The treatment of the larger growths will be referred to below. 

Papillary Epithelioma.— Certain cases begin as true w T arts. Others 
take on a papillary development after beginning as superficial or deep- 
seated epitheliomata. When fully developed they appear as flattened, 
ulcerated, and fissured papillomatous growths, occasionally being 
pedunculated. They are likely to involve the neighboring lymph 
nodes in the same manner as the malignant deep-seated variety. 
When very small, the treatment is the same as in the deep-seated 
epithelioma mentioned above. 




Fig. 89. — Extensive carcinoma of the neck, secondary to a small growth in the mouth. 



Treatment of Larger Epithelioma.— While the treatment of all the 
epitheliomata described above is comparatively simple, they are 
frequently not seen by the surgeon, or the growth causes so few sub- 
jective symptoms that the patient will not permit operation until 
the tumor has reached a considerable size. There is no doubt that 
complete excision is the best method of treatment, but often this causes 
so much deformity that the patient refuses to submit to the operation . 

In the rodent ulcer type, if the skin is excised from one-quarter to 
one-half inch from the edge of the tumor, there is little chance of 
recurrence. If important structures must be removed in order to 
excise the growth completely the surgeon should not hesitate. A 
portion of the nose or ear or of the eyelid should be removed if it is 
involved in the growth. 

In the deep-seated type, the removal should be even more extensive. 
In some cases, a portion of the superior maxilla or frontal bone may 
require removal. A case seen in the out-patient department of a large 



166 INJURIES TO THE HEAD 

New York hospital had been treated for four years by a private 
physician with caustics and conservative excisions for an epithelioma 
of the cheek. After treatment the growth would always recur at some 
point, finally involving the superior maxilla and the floor of the orbit. 
When the patient was referred to the hospital, a radical operation was 
performed, which removed the superior maxilla, the malar bone, the 
eye, and all the tissues as far as the septum of the nose. The patient 
recovered and was alive two years later. There was a marked deform- 
ity, but this deformity took the place of what had been before operation 
a deep, foul-smelling ulcer. 

The treatment of the regional lymph nodes is of extreme importance. 

Some surgeons advise removal of the regional lymph nodes in every 
case, except the small, slow-growing, superficial epithelioma. Others 
advise removal only when the glands are palpable. It would seem 
that the extra operative risk, attendant upon the general anesthestic 
as required for a thorough removal of the glands of the neck, is hardly 
justified for a growth on the cheek the size of a pea, while it is certainly 
justified in the case of a deep growth the size of a silver dollar. Some- 
where between these lie the point where the distinction is to be made 
A good rule is to remove the glands when they are palpable, when the 
growth is advancing rapidly, or when it appears to show a tendency 
to invade the deeper tissues. That is, the glands are to be removed 
when the tumor appears especially malignant. Beginning growths 
and growths which have existed a long time with only a slight increase 
in size rarely involve the glands. 

Roentgen Ray.— During recent years remarkable results have been 
reported, following the exposure of superficial growths to the roentgen 
ray. 

The result in epithelioma of the face has been particularly happy. 
To secure the best results, repeated treatments are necessary and great 
care must be exercised as to dosage. In experienced hands, it is a 
method of the greatest value. In inexperienced hands its application 
may stimulate the growth. 

In cases that are considered inoperable, the application may serve to 
cause partial healing and marked amelioration in the symptoms. In 
rare cases a cure has resulted. 

Radium has been used recently. It has found its greatest success in 
cases of the type under consideration, complete cures having been 
frequently reported. Its use is too recent to have outlined definite 
indications for its use, and for the present at least, its use had better 
be restricted to inoperable cases. 

Some of the more recent methods, fulguration, electro-coagulation, 
phototherapy, etc., are still under trial. In general the results have not 
been promising. 

Epithelioma of the Lip.— This is likely to follow chronic irritation of 
the lip as from a pipe, or a cigar, or from the jagged edge of a broken 
tooth. In a case recently seen, the patient had carried a pipe in the 



MALIGNANT TUMORS OF THE HEAD AND FACE 



167 



corner of the mouth until it had worn a semicircular opening in the 
teeth of the upper and lower jaw. This opening was so large that, 
although the jaws closed perfectly, the stem of the clay pipe could be 
inserted between the teeth without opening the jaws. Directly 
opposite the groove, on the lower lip, was a rapidly growing epithelioma. 
Epitheliomata of the lower lip are likely to involve the glands early. 
They must be differentiated from the chancre and the tuberculous 
ulcer. If there is doubt, it is well to excise a portion for microscopic 
examination. This is accomplished as follows: The ulcer is anesthe- 
tized by the injection of 0.5 per cent novocain around the growth (not 
into it), and a V-shaped piece is excised from the indurated edge of the 
ulcer. Never excise from the center, as the tissues are so changed 
here by ulceration that they are unsuitable for pathologic examina- 
tion. The aim should be to secure a piece of the advancing edge of 




Fig. 90. — Epithelioma of the lower lip in a man, aged seventy-one years. Duration, six 
months. Inoperable ; extensive cervical involvement. 

the growth together with the adjoining normal tissue. It is not 
advisable to suture the incision made. If only a small piece, about 
the size of a split pea, is removed, bleeding can be ignored. 1 

Treatment. —If it is not deemed necessary to remove the glands of 
the neck, the ulcer may be excised under local anesthesia. This is best 
accomplished by having an assistant grasp the lip between the thumb 
and finger on both sides of the growth. This usually controls the circu- 
lation through the inferior coronary and inferior labial arteries. The 
lip is now anesthetized, care being taken not to insert the needle into 
the growth. A V-shaped piece of skin is excised, beginning above by 
two incisions which meet on the chin. They should be at least one- 
third of an inch from the growth. The hands release the two sides of 



1 A single exposure to radium several days before the incision is made tends to lessen 
the danger of spreading infection by this method. 



168 INJURIES TO THE HEAD 

the lip and the bleeding points are caught and tied. The wound is 
sutured with silk, the sutures passing nearly to the mucous membrane, 
but not penetrating it. Usually these sutures will hold the wound 
together so that there is no gaping, but if the mucous membrane tends 
to gape, it may be sutured with a continuous suture of fine silk. 

Advanced cases of lip cancer may be treated in the radical manner 
outlined above for epithelioma of the face, care being taken to remove 
the glands in every case. 

Epithelioma of the Tongue.— Epithelioma of the tongue may begin 
spontaneously or it may follow as a complication of leucoplakia, a 
chronic degenerative condition of the tongue characterized by the 
formation of hard, whitish patches on the dorsum of the tongue. 

Irritation caused by the rough edge of a broken tooth or a sharp 
projection on a dental plate may be a predisposing cause. Epithelioma 
of the tongue occurs frequently in association with pyorrhea alveolaris, 
but it is not possible to say that the relation is more than a casual one. 

Simple ulcer may take on a malignant character after having existed 
for several months or longer. It is possible that these so-called simple 
ulcers are really beginning epitheliomata which are very chronic and 
show few malignant characteristics. 

Epitheliomata of the tongue usually occur on the tip or the lateral 
margins, less commonly on the dorsum of the tongue. The early 
stage may show as a small ulceration or as a papillomatous growth, 
without superficial ulceration. 

Treatment.— Any small persistent ulcer or papilloma of the tongue 
should be removed at the earliest possible opportunity. As early 
involvement of the glands of the neck is the rule, only in beginning 
growths can the operation be limited to the tongue. The tumor may 
be removed, together with enough of the surrounding healthy tissue, 
to make certain of complete eradication of the local lesion. The 
incision in the tongue is sutured together with deep silk sutures and an 
antiseptic mouth wash is prescribed. 

After a few months, the tongue adapts itself to the deformity so that 
speech becomes normal or nearly so. 

In larger growths where there is induration, either with or without 
palpable enlargement of the cervical nodes, half or more of the tongue 
should be removed and the lymph nodes should be cleaned out of the 
submaxillary triangle. Even with this operation, the result is uncer- 
tain. Often there is early recurrence. 

During recent years very many cancerous growths of the tongue 
and lip have been treated with radium. The ordinary plan is to apply 
the proper dosage of radium to the growth and to remove the glands 
of the neck if palpable. The glandular region of the neck also receives 
an application of radium emanation. To secure the best results in 
these cases the growth should be treated during the operable stage. 
Excision of the growth with the cautery followed by radium or roentgen 
rays has been advised and a small number of favorable results have 
been reported. 



MALIGNANT TUMORS OF THE HEAD AND FACE 



169 



Sarcoma of the Face. — Sarcomata of the face and scalp are rare but 
they occur occasionally in the region of the jaw and about the socket 
of the eye. It is not uncommon to remove a small tumor of the skin 
which has given a history of slow growth and is most benign in appear- 





Fig. 91. — Sarcoma of the antrum. 
Edema of the lower lid in a man, aged 
thirty-nine years. Duration, eighteen 
months. 



Fig. 92. — Osteosarcoma of the jaw in 
a man, aged sixty-one years. Duration, 
ten months. 





Fig. 93. — Epulis in woman, aged thirty-seven 
years. Duiation, six months. Removal. 
Cure. 



Fig. 94. — Granuloma growing 
from tooth socket. Tooth re- 
moved one week before, simulating 
epulis, cured by curetting. 



ance, but which proves on microscopic examination to be a sarcoma. 
There is little or no tendency to recurrence in these growths if removal 
has been complete. On the other hand, partial removal or the use of 
caustics may cause the growth to increase rapidly in size. There are 
certain types of sarcomata which are helped by radium. 



170 



INJURIES TO THE HEAD 



Epulis. — This is a small tumor which grows in a pedunculated form 
from the alveolar margin generally in the space between two teeth. In 
its early stages it is a benign growth; while in the later stages it grows 
rapidly and is truly sarcomatous. It should be removed together with 

the mucous membrane at its base. If it is 
growing rapidly, or if it has already reached 
the size of a small marble, it is a wiser pre- 
caution to remove the two adjoining teeth 
and the alveolar margin between the root 
sockets 

Parotid Tumors. — The parotid gland is 
frequently attacked by malignant growths. 
Carcinoma, sarcoma, myxoma, and mixed 
tumors, containing cartilage, bone, and other 
tumor elements, may occur. 

The growth begins as a hard lump, which is 
often lobulated and likely to project con- 
siderably beyond the surface. The skin 
over the tumor is, at first, freely movable 
and the tumor moves with the gland on the 
deeper parts; but as the tumor increases in size, it becomes attached to 
all the surrounding parts. Hardness and rapidity of growth are 
characteristics of this tumor. Removal is the only form of treat- 
ment which offers any hope of cure. Recurrence is the rule, unless 
the tumor has been removed very early. In inoperable cases, roentgen 
ray and radium may be tried but they are much less successful than 
in the slow-growing epitheliomata of the face. 




Fig. 95. — Mixed tumor of 
the parotid. 



PLASTIC SURGERY OF THE FACE. 

After operation upon the face, there is often an extensive area left 
uncovered, which will lead to serious deformity unless it is covered with 
skin. In general, plastic surgery is required for one of three different 
conditions: (1) Removal of portions of the skin as a part of various 
operations; (2) repair of congenital deformities and defects; (3) repair 
of cicatricial deformities resulting from injury or disease. When loss 
of tissue is due to operation, it is better to do the plastic operation at 
once; but when it is the result of disease (ulceration), it is better to 
wait until cicatrization is complete before attempting any form of 
plastic operation. 

Kolle l has outlined five methods employed in performing plastic 
operation. They are: 

1. Stretching the margins of the skin. 

2. Sliding flaps of adjacent skin. 

3. Twisting pedunculated flaps. 

4. Implantation of pedunculated flaps by bridging. 

5. Transplantation of non-pedunculated flaps or skin-grafting. 

1 Plastic and Cosmetic Surgery, New York, 1911. 



PLASTIC SURGERY OF THE FACE 171 

In the making of flaps or undermining the skin, it is important that 
the skin shall have sufficient blood supply. The direction of the 
blood supply and the condition of the underlying subcutaneous tissues 
are important. In undermining for a short distance the skin can be 
separated from the fascia; but where it is necessary to undermine more 
extensively, it is better to leave the fascia attached to the skin, so that 
the blood supply of the skin will not be interfered with. 

Incisions should be made obliquely to the skin rather than at right 
angles. This will give a much smaller scar if the wound edges are 
closely approximated. Sutures should be close together and should 
not be tied too tightly. Horsehair and fine silk are the best materials 
for skin suture. If tension sutures are necessary, silkworm gut should 
be used. 

The simplest plastic operations consist merely in undermining the 
skin and stretching it to fill in the deficiency in the skin surface. When 
the surface is so large that this cannot be done without undue tension, 
the incision must be enlarged and the flap slid into place. The direc- 
tion of the incision and the method of securing sufficient skin depend 
largely upon the size of the opening and the region involved. 

In this connection a knowledge of so-called cleavage lines is import- 
ant. Kocher has outlined the normal incision lines which indicate the 
direction of choice for any given incision. These lines run, in general, 
at right angles to the long axis of the body. If possible, any incision 
should be made to correspond to the direction of the normal line of 
cleavage. 

In most plastic operations, the gap to be bridged over is so large 
that flaps must be pulled or slid over to cover the deficiency. While 
in operative cases it is usually better to do the plastic operation at 
once, it may occasionally be better to wait until cicatrization has taken 
place. The contraction of the scar tends to pull the skin so that the 
space to be filled is less when the scar is excised than it was at the time 
of the first operation. Curved incisions are, as a rule, better than 
straight incisions. They can usually be approximated with less tension 
and there is less damage from the contraction of the resulting scar. 

Any form of dressing for plastic operations about the face is usually 
unnecessary. The irritation of the bandage often does more harm than 
good. If a simple dry dressing is applied for a few hours and then 
removed and the wound dusted with aristol or nosophen, it will heal 
better than when covered with a large dressing. This is especially 
true in wounds about the mouth. Here the dressing soon becomes wet, 
and the maceration of the tissues which results is almost certain to 
lead to suppuration. 

The general health of the patient, upon whom the plastic operation 
is to be performed, should receive appropriate attention; and it is 
important that the inflammatory condition which caused the deformity 
shall have entirely subsided. Syphilis is a frequent cause of failure 
in plastic surgery. In syphilitic deformities no operation is to be 
performed until the local disease is well under control. 



172 



INJURIES TO THE HEAD 



Disfiguring Scars.— Disfiguring scars of the head and neck can 
often be improved by operation. In excising these scars, the incision 
should pass as close to the scar as possible, at the same time leaving an 
edge of normal skin. If necessary, the fascial plane should be separated 
from the skin and smoothly sutured. Where the underlying fascia is 
involved, especially in those cases where it is attached to the bone, 
giving the " dimpled scar" that follows alveolar, periosteal, or bone 
abscesses, it should be completely excised. In scars that involve the 
platysma, the edges of the muscle should be freed and carefully sutured, 
as the pull of an unsutured muscle tends to spread the scar. As 
careful suturing of the underlying tissues relieves the skin of all strain, 
only enough superficial sutures are needed to approximate the skin. 

A keloidal scar can be treated as any other disfiguring scar, now that 
it has been proved that one or two applications of the roentgen ray will 
prevent the new scar from becoming keloidal. 




Fig. 96. — Keloid in scar of neck. Had brush burn in 1907, and keloid was excised 
one month later. Keloid recurred, and present photograph made one year after recur- 
rence. (Ashhurst.) 



Ectropion. — This condition is usually due to cicatricial contraction 
and may involve the upper or lower lid or both. It frequently follows 
severe burns of the lids. The deformity consists of an eversion of the 
lid in such a manner that the conjunctival surface of the lid is 
turned outward. In severe cases the patient is unable to close the 
eye, and the result is constant conjunctivitis from constant irritation. 
A corneal ulcer may result from the same cause. 

When the ectropion is slight in extent, it may be overcome by the 
Wharton Jones' operation. A V-shaped incision is made in the lower 
lid, and the flap is dissected up so as to allow the lid to move into place. 
The incision is then stitched so as to form a Y. 

When the ectropion is more marked, a somewhat better plan is to 
turn in a flap either from the skin over the malar bone or from the 
region above and posterior to the outer canthus. 

The eye is prepared for this operation by washing it well with boric 



PLASTIC SURGERY OF THE FACE 



173 



acid solution and painting the cheek and lids with weak iodine solution. 
Great care must be exercised not to allow the iodine to enter the 
conjunctival sac. It is an additional aid to asepsis if the eyebrow is 
shaved off and the skin of the forehead above the affected eye surgically 
prepared. An incision is made parallel to the lower ciliary margin. 
Two sutures are then taken between the margin of the lower lid and the 
skin of the eyebrow so that when the sutures are tightened the lower lid 
is held on the stretch and a crescent-shaped area of denuded tissue is 
left exposed. From the outer end of this exposed area, a similarly 
shaped flap is formed in a downward direction with its pedicle directed 
slightly upward and backward. This can be swung into place and 
sutured, and the area on the face closed by stretching after preliminary 
undermining of the skin. 

It is better not to apply any dressing about the eye. The wound is 
stitched and sponged dry, after which it is dusted with boric acid 
powder and allowed to remain exposed. A slight discharge from the 
eye may be wiped off daily with gauze wet in boric acid solution, or 
the conjunctiva may be flushed out with the same solution. After the 
fourth day the retention sutures are removed but, owing to the move- 
ment of the lid, it is better to allow the sutures of the flap to remain in 
place for at least seven days or longer. 

Another method is to proceed as above until the lid is sutured to the 
eyebrow. Instead of making a flap, the denuded area is covered by a 
Thiersch skin-graft. The result from this method is less satisfactory 
than from the procedure above described. 

A similar operation may be performed for contraction of the upper 
lid, although this condition, due to the looseness of the skin, occurs 
very seldom. 




Fig. 97. — Rhinophyma. Duration, twenty years. Plastic gave satisfactory results. 



Plastic Operations on the Nose. — Partial Loss of Ala or Tip.— As a 

result of operations and from injuries, a portion of the ala of the nose 
may be lost. This can be repaired by turning over a flap from the 
cheek in such a manner that the skin surface is directed inward toward 
the cavity of the nose, forming the internal surface of the nostril. 



174 



INJURIES TO THE HEAD 



The denuded surface on the face and nose are then covered with skin- 
grafts. 

Loss of Cartilaginous Portion. —This is an operation of some magnitude, 
the nose being formed either by flaps from the cheek or a large flap 
from the forehead. 

Loss of Bridge of Nose.— Usually a result of syphilis or unreduced 
fracture of the nasal bones. This deformity consists of the sinking 
in of the bridge of the nose and a tilting upward of the nostrils. 

In the milder cases, the deformity can be corrected by injecting 
paraffine, which is molded into proper shape after it has been introduced. 
After a while this paraffine becomes replaced by fibrous tissue which 
remains permanently. There is, however, some danger of chronic 
inflammation, due to the irritation of the paraffine. 

In severe cases, operative measures have attempted to replace the 
bony bridge with bone transplated from other parts of the body. A 
rib has been used occasionally with success. One method replaces the 
nose with a finger, which is allowed to heal into place before it is ampu- 
tated from the hand. Several of the methods advised are very ingen- 
ious. They are described by Kolle, and should be studied in detail 
before the operation is attempted. 




Fig. 98.— Cleft lip. Palate normal. 



Harelip. — This is a common congenital malformation. It consists 
in a gap or cleft in the upper lip, and is due to failure of union of the 
congenital clefts. It may be unilateral or bilateral and it is frequently 
associated with cleft palate. 

Treatment.— In the very slight harelip, it is sometimes sufficient to 
pare the edges of the notch in the lip and sew the cut edges together. 
When the opening is deeper, the operation consists of the preparation 
of the flaps so that the deformity can be closed. It is important that 
the vermilion border be accurately approximated and if possible the 



PLASTIC SURGERY OF THE FACE 175 

line of the sutures so placed that the scar runs obliquely to the lip. 
Otherwise the contraction of the scar will tend to reproduce the 
deformity. For the same reason it is desirable to leave a slight excess 
of tissue at the margin of the lip to allow for subsequent retraction. 
If the deficiency is large, it may be necessary to undermine the skin a 
short distance in order to allow the edges to come together. In any 
event, it is a good plan to prevent tension on the suture line by reten- 
tion sutures or by adhesive plaster. 

The mucous membrane and the skin should be sutured with fine 
black silk, which is removed on the fourth or fifth day; but the reten- 
tion sutures or adhesive plaster should be left in place for at least a 
week to prevent tension on the line of incision. For extreme cases of 
harelip reference should be made to the text-books of major surgery. 



Cf\-^L> 





Fig. 99.— Mirault's operation. (Brewer.) 

Tongue-tie. — This condition is caused by a short frenum which 
prevents extension of the tongue. In children this is popularly 
believed to be the cause of backwardness in talking, stammering, etc. 
While this condition is rarely the sole cause of difficulties of speech it 
may interfere to a slight extent and its relief in some cases results in 
marked improvement. The tip of the tongue is forced back with the 
finger, causing the frenum to become tense, when it can be easily 
nicked with a pair of blunt, pointed scissors. The finger then presses 
against the frenum, tearing it backward. This is followed by only a 
slight reaction and requires no further attention. Healing is complete 
within about a week. As the operation is over in less than a minute, an 
anesthetic is not required. The ordinary grooved director which has 
a flat end with a slit, may be used to press back the tongue allowing 
the frenum to present in the slit, where it may be safely and easily cut. 

Cleft Palate. — This condition is usually associated with harelip. 
The cleft may include the soft palate alone or the hard and soft portions 
of the palate or it may be a complete division extending from the naso- 
pharynx to the face. The treatment is confined to operation, the only 
palliative measure being the insertion of an artificial diaphragm, which 
is, at the best, a very unsatisfactory form of treatment. It is import- 
ant to decide upon the best time for operation. Jacobson and Berry 
have advised waiting until the second or third year because children 
are usually in much better physical condition at that time and the 
operation can be done with much better attention to technic and after- 
care, Lane, on the other hand, advises early operation^ that is, within 



176 



INJURIES TO THE HEAD 



the first week, on the grounds that the operative risk is less, that the 
child is usually healthy, and that the early correction of the deformity 
prevents the development of secondary changes in the shape of the 
mouth and nose which are difficult to correct by late operations. 

When the cleft is very small or when it involves only the soft palate, 
the edges may simply be pared and sutured together. When the cleft 
is larger, it is necessary to make a flap of consisting mucous membrane 
and periosteum which can be turned over the opening and attached 
to the opposite side. Several operations have been devised for the 
correction of this deformity. For a description, reference should be 
made to the works on major surgery. 

Plastic Surgery of the External Ear. — Colomba is an injury to the 
lobule of the external ear, occasionally observed in women as a result 
of the use of heavy earrings. Occasionally the condition may occur 
from traumatism or as a congenital deformity. The result is a slit in 
the lobule of the ear which becomes lined with epithelium and remains 
as a permanent deformity. 

The edges of the notch or slit should be cut away, care being taken 
to remove all the cicatricial tissue. The cut edges should then be sewn 
together with fine sutures. 

Enlargement of the lobule may be treated similarly, except that 
instead of excising the edges of the colomba, an inverted Y-shaped 
portion of the lobe is removed and the cut edges sutured together. 





Fig. 100.— Cauliflower ear in wrestler, 
twelve years in profession. 



Fig. 101. — Congenital deformity, 
supernumerary ears. 



Macrotia, or Enlargement of the External Ear.— This condition may 
occur congenitally or it may result from repeated injuries to the ear, 
such as are received by prize-fighters. 

Several methods have been advised for the reduction of the enlarged 
ear, Schwartze's method being one of the most popular. This consists 
in removing an elliptical segment from the pinna through its entire 
thickness and a triangular section from the upper portion of the ear, 



PLASTIC SURGERY OF THE FACE 177 

the base of the triangle being formed by the outer margin of the helix 
and the apex extending to the concha. The Parkhill method is some- 
what similar, but the incision does not enter the concha. 

Auricular Appendages.— Small nipple-like projections of the skin may 
occur on the external ear or on the surrounding skin, either anterior 
or posterior to the ear, or sometimes on the skin of the neck. They 
may contain cartilage and crudely resemble the auricle. When this 
occurs the condition is known as a supernumerary auricle. The 
treatment is simple excision with suture. 

Malposition of the Ear. — Undue prominence of the auricle is a common 
deformity which may be inherited or may result from a faulty position 
of the head during sleep. During infancy much can be accomplished 
by bandaging the ears against the head ; but in later childhood and in 
adult life, operation is required. The earlier the operation is performed, 
the better will be the final result. 

The operation consists of the removal of an elliptical piece of skin 
from the back of the ear, with suture of the skin edges. 

Kolle advises the removal of a portion of the skin from the back of 
the ear and a corresponding area from the skin over the mastoid 
process. He emphasizes the fact that the condition must be over- 
corrected if the best results are desired. 

After operation, the ears should be held firmly against the head, 
care being taken not to bandage too tightly, as severe pain may result. 
A bandage or cap should be worn at night for at least a month. Kolle 
advises especially against moist dressings, which, he says, soften the 
edges of the wound and prevent primary union. 

Deformities of the Cheeks. — In operations for deformities of the 
cheeks it is frequently necessary to remove a piece of skin. The defect, 
if not too large, may be filled in by slightly undermining the edges 
and then suturing with fine silk. One or two retention sutures may be 
of value. If the mucous membrane also shows a defect, it is usually 
advisable to pull over a flap of skin and subcutaneous tissue, allowing 
the mucous membrane to heal by granulation. 

When defects are not too large, Serre's method may be advised. 
He converts the defect into a rectangle and prolongs the ends of the 
rectangle down for several inches into the neck. This forms a flap, 
which must be loosened from the mandible where it passes across the 
inferior margin of this bone. The skin is then slid into place to cover 
the deformity. 

In still larger defects, especially those involving the angles of the 
mouth, it is necessary to turn a flap forward from the neck or uninjured 
portion of the cheek, the defect resulting from the transposition of the 
flap being grafted according to the method of Wolfe or Thiersch. 

As a general rule, plastic surgery of the face should be performed in 
a hospital under general anesthesia. Attempts to perform delicate 
surgery of this type on ambulatory patients are likely to fail because 
of pain at the time of the operation or because of injury to the suture- 
line during healing, 
12 



CHAPTER VI. 
INJURIES AND INFLAMMATIONS OF THE NECK. 

WOUNDS OF THE NECK. 

Severe wounds of the neck are quite common. They are more 
frequently seen as the result of assaults and attempts at suicide than 
as the result of accidents. They are of more significance than similar 
wounds elsewhere, because of the possibility of injury to important 
deeper structures which lie close to the skin on the anterior and lateral 
aspects of the neck. In stab wounds, the trachea or esophagus may be 
punctured, or any of the larger vessels or nerves may be divided. 
Hemorrhage is likely to extend along the fascial planes, sometimes 
becoming quite extensive with only slight evidence externally. Follow- 
ing the injury, the pressure from edema and hemorrhage may be enough 
to embarrass respiration. Nerves are frequently divided, injury to 
the bronchial plexus being fairly common. 

Treatment.— If there is evidence of severe hemorrhage, the wound 
should be enlarged and the bleeding points caught and ligated. If 
the wound is clean, this may be followed by suture without drainage. 
Subsequent interference with respiration as a result of swelling may 
require tracheotomy. For this reason, in bandaging the neck special 
care should be taken not to bandage too tightly. A bandage which 
may be loose enough when applied may become much too tight after 
swelling has occurred. It is a good rule in any bandage of the neck 
to apply the turns loosely enough so that three fingers may be inserted 
beneath the finished bandage without causing constriction of the neck. 
Patients should be instructed to cut the bandage in case it causes 
constriction. The attempt to stop hemorrhage in the neck by a tight 
bandage is a dangerous procedure and is always contraindicated. As 
a temporary expedient to control hemorrhage, wounds may be tightly 
packed with gauze, which should be removed as soon as it is possible 
to clamp the bleeding vessels and ligate them. 

Wounds of the Trachea. — These are usually easily recognized, 
either by direct inspection or by the noise of air passing through the 
wound in forced respiration. Due to the inspiration of blood, there is 
often a persistent cough. Wounds of the trachea should be closed at 
once with fine gut sutures. If allowed to heal by granulation, the 
possibility of secondary pneumonia is always present. As irritation 
and pain make the introduction of sutures very difficult, it is better, 
when possible, to perform the operation under general anesthesia. 
Morphine is required to relieve the persistent cough, which follows 
during the period of healing. 



WOUNDS OF THE NECK 



179 



In some cases the injury is of such a nature that breathing through 
the larynx is difficult or impossible, in which event a tracheotomy tube 
should be inserted through the wound. 

Tracheotomy.— In cases of obstruction of the larynx, the trachea must 
be opened and a tube inserted in order to permit sufficient air to enter 
the lungs. 




Fig. 102. — Tracheal dilator. (Brewer.) 

Tracheotomy is performed as follows: The cricoid cartilage is 
located by palpation, and a vertical incision is made down to the 
trachea just below the cricoid. With a sharp knife, two or three of the 
cartilaginous rings of the trachea are cut through and held open by 
sharp hooks while the tracheal tube is inserted. The wound is now 
sutured above and below the tube, which is fixed in position by a tape 
tied around the neck. If there is sufficient time, all hemorrhage should 
be stopped before the trachea is opened, as the entrance of blood into 
the trachea causes a severe and persistent cough. If the isthmus 
of the thyroid presents in the operating field, it should be drawn upward. 




Fig. 103. — Tracheal tube. (Brewer.) 



After the operation, the tracheal irritation is usually severe and 
requires morphine for its control. A small amount of loose cotton or 
gauze placed over the opening will filter much of the dust from the 
inspired air and thus prevent a certain amount of tracheal irritation. 
If the wound suppurates, it may be washed with a sponge dipped in 



180 INJURIES AND INFLAMMATIONS OF THE NECK 

weak peroxide of hydrogen or other mild antiseptic solution, care being 
taken not to allow the solution to run down the tube. 

The care of the tube is important. Mucous collects rapidly and can 
be recognized by the coarse, bubbling sound heard during respiration. 
It should be removed with a cotton swab, bent to enter the tube. It is 
hardly necessary to call attention to the dangers of allowing the cotton 
to slip into the trachea. It should be so firmly attached to the probe 
that its accidental removal is impossible. The tube should be removed 
and cleansed daily. As the introduction of the tube is always difficult, 
especially after its removal from the healing wound, special double 
tubes are available, which can be removed one at a time, the remaining 
tube acting as a guide for the rein traduction of the other. 




Fig. 104.— Tracheotomy tube in position. (Brewer.) 

An emergency tracheotomy can be performed in much the same 
manner as the above, if the instruments are at hand. If the ordinary 
resources are not available, life may occasionally be saved by a rapid 
incision through the cricothyroid membrane, performed with an 
ordinary penknife. The opening is at the best an unsatisfactory one 
and tends to become closed by the valve-like action of the overlying 
tissues. Consequently, if any sort of tube is available, such as a piece 
of rubber catheter, it should be inserted into the trachea. Owing to 
the possibility of infection and the aspiration of blood and infectious 
matter through the wound, most emergency tracheotomies end 
fatally. 



__ 



CONTUSIONS OF THE NECK 



181 



Intubation.— Intubation is rarely used except in diphtheria and then 
only in those cases where the obstruction is limited to the region of the 
vocal cords. 

The operation requires special intubation tubes (O'Dwyer's tubes) 
and special instruments for the introduction and removal of the tube. 

Experience in the technic is a 
requisite for successful intubation. 
The tubes and the manner of intro- 
duction are described in works on 
laryngology. 

Wounds of the Esophagus. — These 
are recognized by the escape of food 
material from the wound. In case of 
doubt the patient should be given a 
colored solution to drink, such as milk 
or a weak solution of methylene blue 
(one grain to six ounces of water), 
which is easily recognized in the dis- 
charge from the wound . If the wound 
is large enough, it may be possible 
to suture the opening in the esophagus ; 
but in small wounds, it is usually safe 
to permit the opening to heal by 
granulation. In order to prevent the 
collection of foods in the tissues, the 
drainage externally should be con- 
tinued and free until the esophageal 
opening is closed. In some cases the 
external wound heals first, thus pre- 
venting the escape of the infectious 
material from the neighborhood of the 
esophagus. If this condition is al- 
lowed to persist, the infection will 
burrow up and down along the esoph- 
agus and possibly extend into the 
mediastinum. This can be prevented 
by enlarging the external opening whenever the drainage appears to 
be inadequate. 

CONTUSIONS OF THE NECK. 

Contusions of the neck may result from blows or other trauma, and 
are of special importance because there may be an associated injury 
to some of the important deeper structures— the larynx, the trachea, 
the thyroid gland, the spinal nerves, etc. 

Treatment.— The treatment consists of rest in bed and the applica- 
tion of cold compresses, special attention being given to the detection 
of injury to the underlying structures. 




Fig. 105. — Congenital torticollis. 
Deformities of the lower extremities 
due to rickets. 



182 



INJURIES AND INFLAMMATIONS OF THE NECK 



SPRAINS OF THE NECK. 

Sprains are likely to result from forcible twisting or turning of the 
neck, as in wrestling. Every case of severe sprain of the neck should 
cause suspicion of a possible fracture of the cervical vertebrae, which 
should not be excluded until roentgenographic examination is 
definitely negative. 

Treatment.— The treatment of uncomplicated sprain consists of rest 
for a few days, followed by early motion and massage. Unless the 
patient is required to move his neck during the period of recovery, 
a more or less persistent wry-neck may result. 

BURNS OF THE NECK. 

Burns of the neck occur frequently as a result of burning clothing. 
The only special feature is the contraction which follows healing. 
This may be so great in burns situated beneath the lower jaw as to pull 
the chin down upon the chest. During healing the contraction may be 
partially prevented by a plaster bandage so arranged as to draw the 
head in the opposite direction. Later, massage and passive motion 
are of value. 





Fig. 106. — Birth hemorrhage in sheath 
of sternocleidomastoid muscle. 



Fig. 107. — Late result of hemorrhage 
into sternocleidomastoid sheath. Atrophy 
of muscle fibers and replacement by con- 
nective tissue. 



SEPTIC INFECTION OF THE NECK. 

Cellulitis. — Infection of the neck is likely to spread along the fascial 
planes and enter the mediastinum. For this reason it is important 
in all cases of cellulitis of the neck that free drainage should be insti- 
tuted as early as possible. The treatment is the same as for cellulitis 
elsewhere, but the effect of the fascia on the spread of infectious 



SEPTIC INFECTION OF THE NECK 



183 



material must be recognized and the cellulitis incised in the early stages 
in order to prevent extension into the mediastinum. In the back of 
the neck the thick layers of muscles serve as an excellent barrier 
between infections of the posterior neck and the important structures 
anteriorly, so that it is very uncommon to see an infection spread to 
the anterior or lateral aspects when originating behind. 

Treatment.— In operating for cellulitis at the front or sides of the 
neck, the incision should, if possible, be made in the natural folds, so as 
to avoid disfiguring scars. 

Boils. — The most frequent site of boils is the back of the neck, and 
they occur in this location much oftener in men than in women. The 
reason for this may be found in the character of the clothing worn by 
men. A stiff collar serves to rub and irritate the neck and cause minute 




Fig. 108. — Multiple furuncles on the back of the neck. Duration, eight months. 



abrasions which allow the entrance of infection. In addition to this, 
the coat collars worn by men are almost constantly in contact with the 
neck and are continually collecting dirt and dust, which is in turn, 
rubbed into the follicular openings and abrasions in the skin. These 
two factors account for the relative frequency of boils upon the back 
of the neck. As the skin here is very thick and tough, the boil tends 
to spread out laterally more than on other parts of the body, and the 
pus cavity is apt to be more deeply situated. It may begin as a small 
superficial infection about the hair follicles, or it may be deeply situated 
from the beginning, appearing first as a small indurated nodule beneath 
the skin. 

Treatment.— When a boil appears on the back of the neck, the wear- 
ing of a starched collar should be forbidden. If there is a slight 



184 INJURIES AND INFLAMMATIONS OF THE NECK 

discharge from one boil, the collar serves as a medium for reinfection, 
rubbing the pus from the boil to the healthy skin at another location. 
Woolen collars on coats and overcoats, being another source of reinfec- 
tion, should be protected from contact with the infected area. 

Small superficial infections no larger than a split pea may be nicked 
and the inside touched with the end of a small swab dipped in carbolic 
acid. When the superficial boil has developed further or when the 
deeper variety is present, a wide incision is the only plan of treatment 
which is likely to be efficacious. Poulticing, when successful, will 
cause more definite localization of the pus and make the work of the 
surgeon considerably lighter; but, when a boil is beginning, we have no 
way of determining whether it is going to localize early or late, and 
the application of a poultice is likely to allow the development of a 
large boil with induration over a considerable area, which might have 
been prevented by an early incision. After the boil has begun to 
discharge, a poultice, because it causes relaxation of the openings of 
the follicles, is likely to serve only as an agent for the spread of infection. 

If incision is made early enough, the pus escapes and no further 
treatment is necessary. Usually, it is better to keep the wound open 
so that the slough (core) , if present, may separate and the wound heal 
from the bottom by granulation. Owing to the position of the incision 
and the movement of the neck, it has been found almost impossible 
to use rubber tubing for drainage . As a substitute, we have found that a 
strip of gauze, which has been well smeared with an antiseptic oint- 
ment, 1 acts nearly as well. The ointment prevents the sticking of the 
gauze to the edges of the wound, and the oily surfaces aid capillary 
drainage and permit free discharge. The wound should be dressed 
daily and the dressing bandaged to the neck rather than attached with 
adhesive plaster. The irritation of the plaster on the back of the neck 
may give rise to new points of infection. 

In obstinate cases, vaccine therapy is of considerable value. Either 
autogenous or stock vaccines may be used, the beginning dose of 
20 to 40 millions mixed staphylococci being gradually increased at 
intervals of from six to ten days to 200 to 300 millions. The larger 
doses advised by some surgeons have not, in our hands, given satis- 
factory results. 

Carbuncle of the Neck. — The most frequent site of carbuncle is the 
back of the neck. It is apt to extend to enormous proportions in this 
region, the tough skin preventing the discharge of infectious material 
externally, so that the pus is forced to burrow laterally beneath the 
skin. A case recently seen, in which the only treatment had been 
poultices, extended from the occiput to the spines of the scapulas and a 
considerable distance on to the lateral aspects of the neck. This case 
was cured by excision. Carbuncles and boils are likely to be associated 
with diabetes or other general disease and often end fatally. 

1 Such as carbolized vaseline (5 per cent), weak mercurial ointment, etc. 



SEPTIC INFECTION OF THE NECK 



185 



Treatment. — Carbuncle of the neck should be completely excised by 
a circular incision through the normal skin surrounding the lesion and 




Fig. 109.— Wide excision for extensive carbuncle of the neck. Rapid recovery. 




-c 



Fig. 110. — Diagrammatic drawing of a carbuncle. A, cribriform holes in the 
epidermis; B, area of induration ; C, corium; D, subcutaneous tissue; E, abscess formation 
about the hair follicles and sweat glands; F, central area of necrosis; G, deep extravasa- 
tion of pus over fascia covering the muscle; H, deep fascia covering muscle. (Brewer.) 



186 



INJURIES AND INFLAMMATIONS OF THE NECK 



extending down to the healthy muscular tissue. This leaves a large 
wound which heals by granulation, and while it is apparently a very 
radical form of treatment for what is on first appearance a minor 
complaint its routine adoption is advised. There is no greater mistake 
than the conservative treatment of carbuncle, for this almost always 
leads to a prolongation of the disease and occasionally results in the 
death of the patient. 




Fig. 111. — Sequestrum consisting of most of left scapula. 

carbuncle of neck. 



Osteomyelitis secondary to 



Every case of boil or carbuncle should be suspected of diabetes and 
examination of the urine for sugar should be made as a routine. Even 
when the urine is negative, the blood may show an increased sugar 

content, which is apparently often a 
causative factor in the production of 
suppuration of this type. Obstinate 
cases should be placed on a diet con- 
taining a minimum of carbohydrates in 
order to diminish the blood sugar. 

Abscess of the Neck. — This condition 
occurs frequently in children and usually 
on the postero-lateral surface of the neck 
or below the angle of the jaw. Such an 
abscess begins usually as a swollen 
lymphatic node, which becomes en- 
larged and tender and finally breaks 
down, forming an abscess-cavity. The 
posterior abscess occurs just below the 
hair-line on the posterior and external 
aspect of the neck, and is usually due 
to infection from the scalp. Pediculosis is a frequent etiologic 
factor, the scratching of the scalp leading to infection, which in turn 
causes glandular enlargement and abscess formation. Examination 
of the scalp will show evidences of irritation, and the finding of 




Fig. 112. — Large superficial 
abscess of the neck, following 
middle ear suppuration. Dura- 
tion, ten days. 



DISEASES OF THE CERVICAL LYMPH NODES 187 

ova attached to the hairs makes the diagnosis certain. Abscesses 
beneath the angle of the jaw usually arise from infection of either the 
tonsils or teeth. 

Treatment.— Abscesses of this type show little tendency to spread. 
If the cause is removed, they usually remain well localized and point 
externally. For this reason conservative treatment is more apt to be 
successful than in acute abscess occurring elsewhere. They may be 
poulticed or dressed with ichthyol ointment for several days until 
evidences of softening appear. When this occurs, a small incision 
about one-half of an inch in length is sufficient to allow for the escape 
of pus. The only after-treatment that is necessary is the irrigation 
of the wound and the insertion of a small rubber tube to insure free 
drainage. Healing is usually complete in about three weeks, and 
complications are uncommon. In anemic and poorly-nourished 
children, attention should be given to the general health. Local 
sources of infection, such as pediculosis, carious teeth, and chronic 
tonsillitis, should, of course, receive appropriate treatment. Tuber- 
culous abscess of the neck is very common. It will be described under 
Tuberculosis of the Cervical Lymph Nodes. 

Angina Ludovici. — This is an infection of the neck supposedly due 
to the entrance of infection through the floor of the mouth. Owing 
to the attachments of the fascia, the tongue is forced upward against 
the roof of the mouth, and the swallowing of food is difficult or impos- 
sible. Edema of the glottis and death may follow. If the neck is 
examined, the tissues are found hard and indurated, especially beneath 
the chin. Later, the infection may spread beneath the deep fascia 
over the entire anterior and lateral surfaces of the neck. The treat- 
ment consists of early radical incisions with free drainage and stimula- 
tive measures to support the strength. 

DISEASES OF THE CERVICAL LYMPH NODES. 1 

Acute Lymphadenitis. — The cervical lymph nodes may become acutely 
enlarged from a variety of causes. Slight or moderate enlargement 
accompanies many of the infectious diseases, especially scarlet fever, 
diphtheria, tonsillitis, and measles. An acute febrile disease, somewhat 
loosely described as " glandular fever" occurs, in which the only evident 
lesion is the enlargement of the lymph nodes. The regional nodes 
may be enlarged secondarily to an infected wound, or following infec- 
tion of one of the cavities of the nose. In surgical practice, the most 
frequent causes of enlarged nodes are pediculus capitis, infection from 
carious teeth, and chronic tonsillitis. With pediculosis, the group of 
nodes situated behind the ear in the posterior cervical triangle is usually 
involved; while tonsillitis and infection from decayed teeth cause 
enlargement of the nodes below the jaw. A single node in the mid- 

1 See also Abscess of the Neck. 



188 INJURIES AND INFLAMMATIONS OF THE NECK 

line, just below the symphysis, is sometimes enlarged by infection 
from the lower incisors or by infection in the floor of the mouth. It 
should be emphasized that the lymphatic drainage from the upper 
jaw passes downward to the same group of nodes as does the drainage 
from the lower jaw. This fact is not generally appreciated, and 
consequently carious teeth in the upper jaw are often overlooked as a 
source of infection of enlarged submaxillary nodes. 

When the lymph nodes become enlarged, they may resolve and 
become normal in size; they may remain more or less permanently 
enlarged ; or they may gradually become softer, finally breaking down 
with distinct fluctuation, forming an abscess (see Abscess of the Neck) . 

Whenever the nodes remain enlarged, the suspicion of tuberculosis 
arises, although it is possible for nodes to remain chronically enlarged 
and show no evidence of tuberculosis. In one case which we had under 




Fig. 113. — Acute lymphadenitis. 



observation for a long period, the nodes were enlarged to the size of 
walnuts. When finally they were removed, the largest contained a 
splinter of wood about half an inch in length. Otherwise, they showed 
only acute hyperplasia. There was no pus present and no evidence of 
tuberculosis. There is no rule as to which nodes are going to soften 
and break down and which may be expected to resolve. In general, 
the larger the nodes, the more apt it is to suppurate; but nodes as large 
as hen's eggs frequently resolve, and nodes no larger than walnuts 
sometimes break down. 

When fluctuation occurs, the node becomes fixed in position by the 
inflammatory reaction of the surrounding tissues, and the skin ceases 
to be freely movable. Rupture may occur externally, but more often 
the node breaks beneath the skin, forming an abscess-cavity in the 
tissues of the neck. 



DISEASES OF THE CERVICAL LYMPH NODES 189 

Treatment.— It is most important to seek out the source of infection 
and to remove it. Nodes moderately enlarged will frequently show an 
immediate decrease in size following the removal of infected tonsils or 
carious teeth. If there is no apparent source of infection or if it is 
impossible to remove it, an ice-cap should be applied to the neck, and 
measures taken to increase general elimination. A cathartic, an 
antiseptic mouth wash, and free diuresis, all help to carry away the 
infection. 

When the acute process has begun to subside, the treatment may be 
changed to the application of heat, which will aid resolution. A 
favorite application in cases of threatened suppuration is ichthyol 
ointment (50 per cent) applied thickly over the swollen area. It is in 
cases of this type that poultices act most favorably. There is a modern 
tendency to discard the use of poultices entirely, but this is, in our 
opinion, a mistake. Poultices have been used by careful clinicians 
since the beginning of the science of therapeutics. 1 In our experiments 
we have been favorably impressed in certain cases by the effects 
obtained from the use of simple poultices. These results we ascribe 
to the steady moist heat produced by all poultices which relaxes the 
vessels and tends to localize the pus. They may safely be used where 
free drainage has been established or where there is loose tissue and no 
tendency for the pus to burrow deeply. They should not be used in 
infections of the fingers, toes, palms, wrists, ankle, etc., except after 
an incision to provide drainage, in which case they relieve pain and 
promote free discharge. 

In lymphadenitis it is advisable not to operate until suppuration has 
occurred. This is a notable exception to the general rule of early 
incision. The infectious organism appears to be attenuated by the 
action of the lymphatics and there is little or no danger of spreading 
infection. The time of choice is when the node is broken down, but 
before it has ruptured into the surrounding tissues. Usually, only a 
small puncture is necessary, the wound being kept open by a rubber 
tube or by a strip of gauze smeared with a mild antiseptic ointment. 
Healing is usually complete within a few weeks. Occasionally two or 
more nodes in different parts of the neck may break down either 
simultaneously or at different times. Separate incisions are usually 
necessary. 

Chronic Lymphadenitis. — This is usually tuberculous but may be. a 
simple inflammation due to chronic or subacute infection about the 
tonsils or teeth, or elsewhere. It may also occur in syphilis, either as 
part of the general enlargement of the nodes, or as a result of septic 

1 Poultices are a favorite home-remedy used by all races. In locations a considerable 
distance from the conveniences of civilization, poultices are usually made from whatever 
material may be on hand. Thus, in the South Sea Islands poultices are made from a 
split fish or pounded seaweed; in the Arctic, strips of blubber are used; while the bushmen 
use wet moss and pounded herbs. Plainsmen make poultices from a prairie-chicken 
split open or from fresh sheep, or cow-manure. The ordinary household poultices of 
bread and milk or flaxseed are familiar to all. 



190 



INJURIES AND INFLAMMATIONS OF THE NECK 



infection from the ulcerative sore throat which occurs in the secondary 
stage. Syphilitic enlargement, when due to general infection, requires 
no special treatment; but when it is due to an infected throat, the node 




Fig. 114. — Large superficial cyst under chin, many years' duration, following breaking 

down of submental lymph node. 

may have to be incised. Ordinarily, syphilitic nodes subside rapidly 
under antisyphilitic treatment. There is also a chronic enlargement 




Fig. 115. — Large cervical lymph nodes with mediastinal mass. Removed nodes 
diagnosed as Hodgkin's disease. Condition slowly cleared up after removal of diseased 
tonsils. 



of the cervical nodes which occurs fairly frequently and without 
apparent cause. As such cases show simple chronic inflammation, 
it is probable that they are the result of an infection, the location of 



DISEASES OF THE CERVICAL LYMPH NODES 



191 



which is not demonstrable. Chronic infection of the accessory sinuses 
or nasopharynx should be suspected. 

Enlargement of the cervical lymph nodes occurs as a part of the 
general glandular swelling in leukemia, in Hodgkin's disease, and in 
malignant disease. Frequently, an unsuspected cancer is first brought 
to notice by the enlargement of the lymph nodes. Carcinoma of the 
esophagus or stomach may first become apparent in the nodes of the 
neck, especially those above the left clavicle. 

Treatment.— Syphilitic lymphadenitis requires general antisyphilitic 
treatment. In chronic enlargement, due to infection, the foci of 
infectious material must be removed and the nodes treated by the 
application of ichthyol ointment or counter irritation. The use of 
heat applied by means of the incandescent lamp often acts favorably. 
As a rule the glands should not be incised unless there is definite 
evidence of abscess formation. When the nodes continue to enlarge 
in spite of treatment, one of the nodes should be removed under local 
anesthesia and examined microscopically. Occasionally, a hitherto 
unsuspected cancer or Hodgkin's disease will be revealed. 




Fig. 116. — Early tuberculosis of the lymph nodes, with rapid destruction and abscess 
formation. Nodes noted for two weeks. Throat clear. 



Tuberculosis of the Cervical Lymph Nodes. — Tuberculosis lymph- 
adenitis may begin insidiously, or the nodes may be enlarged as an 
acute lymphadenitis and then fail to resolve completely. After a 
period, the tuberculous character of the nodes becomes evident. It is 
impossible to say in these cases whether the condition is a lighting up 
of an old tuberculous process or whether tuberculosis is secondary 
to the inflamed condition of the nodes. Chronic tonsillitis and carious 
teeth have recently been held accountable for a large percentage of 
cases of tuberculous cervical nodes. When the process begins, the 
nodes are palpable as single nodes and freely movable. Later they 
become matted together and surrounded by inflammatory tissue. 
When incised, they show thick, greenish-white pus occasionally con- 



192 



INJURIES AND INFLAMMATIONS OF THE NECK 




taining granules of calcareous material. In advanced cases numerous 
sinuses are present, the openings appearing reddish-blue and sluggish, 
and the surrounding area of the neck showing the fibrous induration 
of chronic inflammation. 

Treatment.— The treatment may be divided into general and local. 
The general treatment consists of attention to hygienic conditions, 
good food, fresh air, and sunshine. There can be no doubt that the 
fresh-air treatment as given in chronic pulmonary tuberculosis is of 

value in tuberculosis of the lymph nodes. 
Sea air has been advocated by some ob- 
servers as better than the air of high 
altitudes in this particular condition, but 
this has not been definitely proved. In 
any event, fresh air, no matter where 
obtained, seems to be decidedly beneficial. 
Surgical opinion is not definitely de- 
cided as to the advisability of the removal 
of the diseased nodes. The radical re- 
moval of the nodes is the generally ac- 
cepted treatment. Admitting that the 
tonsils and the decayed teeth may repre- 
sent the portals of entrance, most surgeons 
advise the removal of these foci of infec- 
tion in addition to the enlarged nodes; but 
a few advocate simply the removal of 
infectious foci combined with conservative treatment of the nodes, 
operating upon the nodes only when abscess formation is present, and 
in such cases limiting the operation to simple incisions. 

The radical operation consists of the complete removal of all enlarged 
nodes together with the node-bearing fascia. This, it is urged, removes 
the largest number of foci and makes recurrence of the disease less 
probable. The operation is a serious one, and requires general anes- 
thesia and a large incision. Its advocates claim that although there is 
a large scar, there is less disfigurement than from the sinuses and 
cicatrices of the non-operative cases. When there are many nodes to 
be removed or when there is considerable cicatricial tissue present, the 
operation requires careful dissection and complete exposure of the 
structures of the neck. 

A third group of operators take the middle ground, removing only 
the large nodes in which suppuration is imminent, and leaving the 
smaller nodes to be dealt with at a later date unless they disappear 
under general treatment. 

When a simple discrete node is to be removed, it can usually be 
accomplished under local anesthesia. The incision should be made 
over the node parallel to the normal folds of the neck and carried down 
to the capsule of the node, pushing aside any important overlying 
structures. The capsule is cut and, if inflammation has not caused 



Fig. 117. — Cervical retro- 
clavicular and left axillary nodes 
enlarged. Diagnosed as Hodg- 
kin's disease; proved to be tuber- 
cular. 



DISEASES OF THE CERVICAL LYMPH NODES 



193 



adhesions, the node can easily be shelled out. If the node is necrotic 
and surrounded by adhesions, it is necessary to dissect it out; but care 
should be taken to keep close to the node so as not to injure important 
adjacent structures. When the node has been completely removed, 
the wounds should be cleansed with saline solution and closed by 
suture. If, for any reason, the entire node cannot be removed, it is 
well to leave a strip of gauze as a drain at the lower angle of the wound. 
However, this should be avoided, when possible, as the resulting sinus 
is very persistent, lasting in most cases for several months or longer. 
After operation, the wound should be covered with sterile gauze and 
a thick layer of cotton bandaged over the dressing. A starch bandage 
applied over this and extending across the back of the neck and around 




Fig. 118. — Extensive tubercular involvement of all the cervical glands in girl, aged 
twelve years. After removing the tonsils, three months of roentgen-ray treatment 
reduced the neck to normal size. 



the forehead tends to prevent motion of the neck. In children, it is 
sometimes advisable to include the shoulders in the starch bandage so 
as to make fixation more complete. The sutures should be cut on the 
fifth day and removed on the seventh, unless there is considerable 
tension, in which event they may be left a day or two longer. The 
earlier the sutures are removed, the less scarring will result. 

Other plans of treatment have recently been advocated, chief among 
which are tuberculin treatment, roentgen-ray treatment, and aspiration 
and injection of tuberculous abscesses, when they occur. 

Tuberculin Treatment. — During recent years tuberculin therapy, 

especially in cases of so-called surgical tuberculosis, has been widely 

used. There is a wide difference of opinion among surgeons as to the 

value of tuberculin. Some maintain that it should be used in every 

13 



194 INJURIES AND INFLAMMATIONS OF THE NECK 

case of surgical tuberculosis, while other observers state that it has no 
influence on the disease. Again, the middle ground seems to offer 
the best basis for its use. To one who has used tuberculin extensively, 
there can be no doubt of its therapeutic value, when the proper dosage 
is given in selected cases. In the hands of the inexperienced it is 
capable of doing great damage. Combined with the other recognized 
hygienic measures, and used properly, the results are often beneficial, 
occasionally remarkable. 

Tuberculin may be used in closed tuberculosis or in "open" cases 
with sinus formation. The best results are seen in the latter type. 
Various preparations have been used; Koch's old tuberculin (T.O), 
the new tuberculin (T.R), bacillary emulsion (B.E), and many others, 
all have their advocates. For uniformity of preparation and results, 
the bacillary emulsion seems best adapted to general use. This 
preparation comes in solution, 1 cc of the emulsion being equivalent 
to 5 mg. of dried tubercle bacilli. 

Owing to the use of the term milligram to signify cubic millimeter, 
there has arisen some confusion as to the dosage. Although each cubic 
centimeter of bacillary emulsion contains 5 mg. of dried bacilli, the dose 
of 0.1 mg., which is often spoken of, refers to y~o °f a cubic millimeter 
of the original emulsion, and does not refer in any way to the 5 mg. 
of dried tubercle bacilli which it contains. In the following description, 
the term milligram will always be understood to refer to the approxi- 
mate equivalent, one cubic millimeter. Although not a strictly accu- 
rate terminology, it has the sanction of wide usage. 

There are two methods of giving tuberculin: One aims at the estab- 
lishment of immunity and begins with small doses (0.001 to 0.01 mg.) 
and gradually works up to 0.5 to 1 cc of the pure emulsion; the other 
aims at increased reaction and begins with minute doses (0.000001 mg. 
or smaller) and slowly increases the doses until a reaction is noted, 
continuing at approximately the dose which causes a satisfactory local 
reaction, which is rarely larger than 0.01 mg. The latter method has 
given us the better results. It is certainly much less likely to cause 
serious ill effects in unskilled hands. 

The dilutions can be secured already made up, or they can be made 
up by any bacteriological laboratory. The convenient method of 
making dilutions is to add 0.1 cc of the original emulsion to 9.9 cc of 
water. 1 cc of this solution then equals 0.01 cc of the original 
tuberculin. If 0.1 cc of this solution is added to 9.9 cc of water, a 
solution is obtained 1 cc of which equals 0.1 mg. of tuberculin. Another 
dilution made in the same manner gives a solution in which each cc 
contains 0.001 mg. The next step gives a dilution, 1 cc of which equals 
0.00001 mg. 

If the first dose is given as 0.1 cc of the weakest dilution, the result 
is a dose of 0.000001 mg. of the tuberculin, that is, one-millionth of a 
milligram. A special tuberculin syringe that is graduated to 
hundredths of a cubic centimeter should be secured for this work. 



DISEASES OF THE CERVICAL LYMPH NODES 195 

The dose is begun at about 0.00001 mg. in adults, but smaller doses are 
advisable in children, the tuberculin being injected into the sub- 
cutaneous tissues of the arm or back. After an interval a second dose 
is injected (usually double the first), and this is continued until the 
patient is taking 1 cc of the dilution used. The next dose should be 
0.02 cc of the next solution. For the convenience of dosage it is often 
advisable to have solutions between the ones mentioned above, so 
that there are dilutions representing each decimal point. That is, 




Fig. 119. — Extensive tubercular involvement of the tendon sheaths and the small bones 

of the hands and feet. 

1 cc equals 0.01 mg.; 1 cc equals 0.001 mg.; 1 cc equals 0.001 mg., 1 cc 
equals .00001 mg., etc. 

When the stronger solutions, that is, above 1 cc, equal 0.001 mg., it 
is better to increase less rapidly. 

The duration of the treatment and the length of the interval are 
important. In clinical practice, the doses are given weekly, because 
this is found to be the most convenient interval. In private practice, 
the interval may vary from five or six to nine or ten days depending 
upon the reaction and the strength and general health of the patient. 



196 



INJURIES AND INFLAMMATIONS OF THE NECK 



We have rarely found it advisable to keep up a course of treatment for 
more than five or six months. A rest period seems especially beneficial 
in treatment of the glands of the neck, giving time for the tissues of the 
body, stimulated to new activity by the injections of tuberculin, to 
accommodate themselves to new conditions and to devote their action 
solely to the repair of the tuberculous lesion. 

The dosage should depend somewhat upon the reaction of the 
patient. A general reaction is undesirable, but a local reaction at the 
point of injection does no particular harm. A slight focal reaction, 
shown by increased redness and tenderness of the lesion and by a slight 
increase of discharge, is ordinarily taken as a good sign. When this 
stage is reached, the dose is large enough for the time being and should 
not be greatly increased. The local reaction should be allowed to 




Fig. 120. — Chronic osteomyelitis of the right humerus since childhood, with shorten- 
ing of humerus. Patient, aged twenty-seven "years. Several small pieces of bone were 
removed after which the wound healed under tuberculin treatment and was still closed 
seven months after treatment. 



subside before the next dose is given. Of the general symptoms, the 
weight is the most important. A steady gain of weight indicates that 
the treatment is securing desired results. Loss of weight is a warning; 
and a steady loss of weight i& an indication to decrease the dosage or 
discontinue the treatment. It is not uncommon to see a patient who 
has lost weight during treatment suddenly gain ten or twelve pounds 
above his initial weight, with a corresponding marked improvement of 
the local lesion when treatment is temporarily discontinued. 

The larger doses of tuberculin may cause serious injury to the 
patient unless carefully controlled. The details of this plan of treat- 
ment will be found in works on tuberculin therapy. 

Heliotherapy, or the treatment by light-rays, has recently been highly 
recommended by R oilier of Switzerland. He treats children suffering 
from surgical tuberculosis with direct sunlight, not only upon the 



DISEASES OF THE CERVICAL LYMPH NODES 



197 



diseased area but over the entire body. The dosage must be carefully 
regulated. Rollier begins with exposures of five minutes three times 
daily, only a portion of the body being exposed. Gradually, the time 
of exposure and the area exposed are increased until the entire body is 
exposed to the rays of the sun. After a time the children are allowed 
to play in the sun almost completely naked. It is claimed that marked 
pigmentation of the skin is favorable to healing. 

While Rollier's treatment is 
possible only in regions of almost 
daily sunlight, a modified plan 
of treatment may be practised 
in America. Cases of tubercu- 
losis, especially those with dis- 
charging sinuses, do well if all 
dressings are removed and the 
parts exposed to direct sunlight. 
The attempt should be persisted 
in until there is distinct tanning 
of the skin over the diseased 
area. 

Heliotherapy in the form of 
artificial light may also be used 
to aid healing. The ordinary 
incandescent light has been re- 
commended by Crile in the 
treatment of tuberculous ab- 
scesses as well as of wounds 
infected with other organisms. 
Especially rapid results may be 
obtained by the quartz mercury- 
vapor light. It is claimed that 
the quartz globe allows the ultra- 
violet rays to pass freely, while 
ordinary glass obstructs most of 
them. With a strong mercury- 
vapor light of this type, it is 

possible to obtain a mild dermatitis following exposure for ten 
minutes. This dermatitis appears, as does sunburn, only after an 
interval of several hours and is followed by pigmentation of the skin 
exactly in the same manner as in natural sunburn. As the pigmenta- 
tion becomes marked, the length of exposure is increased to thirty or 
forty minutes. An exposure of such length applied before pigmenta- 
tion would result in a severe burn. The results from the use of this 
light have been most promising. 

Roentgen Therapy.— The employment of roentgen rays in the treat- 
ment of tuberculosis has been advised in both open and closed ones. 
The results, except in superficial ulcerative cases, have not been wholly 




Fig. 121. — The Alpine sun lamp, using 
quartz burner. 



198 INJURIES AND INFLAMMATIONS OF THE NECK 

satisfactory. 1 Occasionally, deep glands may decrease in size and 
finally disappear, but often there is a fibrous change which makes 
subsequent operative procedures very difficult. The use of the 
roentgen rays should be under expert control, otherwise severe, deform- 
ing burns may result. The technic of the administration and the 
dosage is given in works on roentgen-ray therapy. 

Radium has been used, but the results have been too recent and too 
contradictory to allow of any definite conclusions. 

Passive Hyperemia.— Bier recommends the treatment of tuberculous 
processes by means of passive hyperemia. This can be secured by 
suction, or by a bandage so applied as to obstruct the venous circulation 
without markedly interfering with the arterial. To obtain the best 
results, hyperemia should be practised for at least an hour or longer 
daily. In the sinuses often seen in the region of the neck, a cup may 
be applied so as to cause suction around the mouth of the sinus. This 
draws the blood to the surface and tends to make the sinus empty 
itself. 

Aspiration and Injection.— In some cases where it is desirable to 
avoid a scar, and especially in the so-called cold abscesses where mixed 
infection is not present, attempts have been made to remove the accum- 
ulation of tuberculous pus without incision. In these cases, the skin 
is cleansed as for a surgical operation, and a large-sized needle on a 
30 cc syringe is inserted into the abscess-cavity. The fluid is removed 
by suction, and a solution of formaldehyde and glycerin 2 is injected 
into the abscess-cavity. Following this, there is considerable reaction 
and a moderate amount of pain, which subsides in a day or two. After 
a week or more, the operation may be repeated. In favorable cases, 
three or four treatments result in a marked decrease in the size of the 
swelling, and an apparent cure may result. The addition of iodoform 
(5 to 10 per cent) to the formaldehyde-glycerin mixture apparently 
increases its efficiency. In large abscesses it should be used with care 
as symptoms of iodoform poisoning may result. In general, aspiration 
is unsatisfactory, most cases finally coming to operation. 

FRACTURES AND DISLOCATIONS OF THE NECK. 

Fractures of the Cervical Vertebrae. — Fractures and dislocations of 
the cervical vertebrae are very serious conditions, resulting frequently 
in instant death or in permanent paralysis. Severe cases are recog- 
nized by the deformity and the paralysis. The indicated form of 
treatment is reduction by traction, and support with a plaster jacket 
extending from the waist to the occiput. 

Since the advent of the roentgen ray, it has been shown that fracture 

1 During the last two years we have seen some exceedingly favorable results follow 
roentgen-ray therapy. This form of treatment gives promise of excellent future results. 

2 Liquor formaldehyde 2 parts; glycerin 100 parts. This solution should be allowed 
to stand several days before use. 



FRACTURES AND DISLOCATIONS OF THE NECK 199 

of the vertebrae without displacement is not uncommon. The spine, 
the posterior arch, and transverse processes, have all been found 
fractured in cases showing no cord symptoms. Many of these cases 
were formerly thought to be sprains of the neck and were treated as 
such. 

Except for the fracture of the spinous process, which can be made 
out by direct examination, the diagnosis is always based upon the 
roentgen-ray findings. Given a history of injury to the cervical spine 
associated with tenderness and pain on motion, a careful roentgen-ray 
examination should be made to determine the presence or absence of 
fracture. In most cases where there is only slight crushing of the 
body of the vertebrae or fracture of the vertebral arches without dis- 
placement, several exposures may be required before the fracture may 
be demonstrated in the negative. It must be remembered that 
splinters of bone may be broken off and the periosteum may be torn 
without showing in the roentgen ray. In such cases, a roentgen ray 
taken seven or eight weeks later may show evidence of callus formation, 
in spite of the fact that earlier plates were negative. 

Treatment.— The treatment depends upon the time that has elapsed 
since the injury. In cases seen early, during the first week, the possi- 
bility of displacement requires that the head and neck be placed in a 
suitable support, such as a plaster jacket and collar. Ordinarily, the 
nature of the injury is not suspected until persistence of pain brings 
the patient to the surgeon several weeks after the injury. Under these 
circumstances, there is no point in applying any form of fixation 
apparatus except a firm adhesive-plaster strapping to relieve the strain 
upon the back of the neck. After a few weeks have elapsed, the 
strapping is permanently removed and the movements of the neck 
increased. Massage, begun early and gradually increased as the 
lesion heals, is of value in the relief of pain and stiffness. Fracture of 
the spinous process alone requires no special treatment, except strapping 
with adhesive tape to prevent excessive movement of the neck. 

Dislocation of the Cervical Vertebrae. — The most common points of 
dislocation are the articulations between the third and fourth and the 
fourth and fifth vertebrae. As in the case of fracture, the injury, when 
complete, is associated with pressure symptoms, and is very likely to 
be fatal immediately. 

Reduction in complete dislocations should be attempted as soon as 
the patient can be given an anesthetic. Traction in the long axis 
of the body is the only method applicable. After reduction, the neck 
should be fixed in a plaster jacket and collar. Attempts at reduction 
may result in instant death, but this should be weighed against the fact 
that any pressure symptoms which exist are likely to be permanent 
and may in themselves cause death. In cases of dislocation with no 
cord symptoms, the advisability of attempting reduction may be 
questioned. This extremely difficult question must be decided only 
after careful consideration of the type of the dislocation and the 



200 INJURIES AND INFLAMMATIONS OF THE NECK 

possibility of reduction without injury. In most cases, it is better 
surgery to fix the neck and shoulders with a plaster jacket and collar 
and to postpone any attempt at reduction until careful roentgen rays 
have been obtained. 

In both fracture and dislocation of the cervical vertebra*, many 
cases arise in which operative reduction with the removal of a portion 
of the vertebrae is less dangerous than attempts to reduce the bones 
without open operation. 

Fracture of the Hyoid Bone. — The hyoid bone is broken by direct 
blows and by constricting pressure such as is seen in attempts at suicide 
by hanging. 

The diagnosis is based on the direct examination of the bone, pain on 
speaking or swallowing, swelling, and, occasionally, by crepitus. Swal- 
lowing may be impossible in some cases, and hemorrhage into the 
throat is not rare. Fracture of the larynx is a frequent complication. 

Treatment.— If there is no displacement, the bone will heal without 
any treatment. In cases where there has been marked displacement, 
satisfactory results have followed operation with suture of the frag- 
ments. Owing to the movement of the bone in swallowing, it is 
impossible to apply any form of immobilization. In cases where there 
is marked dysphagia, it may be necessary to nourish the patient by 
means of an esophageal tube for a few days. 

Fracture of the Larynx. — While this is a rare fracture, it is important 
because of the high mortality. While exact figures are not available, 
the tendency being for the fatal cases to be reported while the mild 
cases are often unrecognized, it is certain that a large number (possibly 
30 per cent) of such fractures result in death. The causes are the same 
as in fractures of the hyoid bone, the two conditions being frequently 
associated. 

In mild cases, the only symptoms are pain on swallowing, tenderness, 
and hoarseness. It is difficult to locate the tenderness exactly, because 
the blow which causes the fracture bruises the neck so that the tender- 
ness is more or less general in location. In a few cases, laryngoscopic 
examination will show an area of of ecchymosis. 

In severe cases the above symptoms are intensified, and in addition 
there is hemoptysis, dyspnea, convulsive coughing, and when the 
mucous membrane is torn, subcutaneous emphysema extending over 
the neck and chest. The dyspnea is likely to progress slowly until 
there is a sudden edema of the glottis, which ends in death. In a few 
cases, this severe type of dyspnea does not make its appearance until 
several days after the accident. 

Treatment.— No special treatment is necessary in mild cases. The 
tendency to laryngeal swelling will be influenced by rest and by 
applying cold compresses to the neck. 

In the severer cases, the question of tracheotomy is to be decided by 
the extent and progress of the dyspnea. Remember that a mild 
dyspnea may change in a few minutes to edema of the glottis with a 



TUMORS OF THE NECK 201 

fatal result, and the importance of early tracheotomy becomes apparent. 
In any case, the patient should be under close observation until the 
dyspnea begins to disappear. After a successful tracheotomy has been 
performed, the patient may die on the third or fourth day from broncho- 
pneumonia. 

Fracture of the Trachea. — The causes and symptoms of fracture of 
the trachea are very similar to those of fracture of the larynx. The 
history of injury, followed by dyspnea and hemoptysis with a local 
point of tenderness over the trachea, is usually sufficient evidence upon 
which to base the diagnosis. 

Treatment.— The indicated treatment is tracheotomy with the 
insertion of a tube beyond the point of fracture. In many cases this 
is impossible, and in those in which it is successful bronchopneumonia 
is likely to follow, as in fracture of the larynx. Mild cases may be 
treated expectantly. 

TUMORS OF THE NECK. 

Practically all tumors which occur upon the face are found also on 
the neck. Of the benign tumors, sebaceous cysts, papillomata, 
fibromata, and dermoid cysts are found on the neck, and the treatment 
varies according to the location of the tumor, but is in general the same 
as that of similar growths on the face. Carcinoma, epithelioma, and 
sarcoma occur in the neck as both primary and secondary growths. 

Hair-cysts. — A hair-cyst is of rather common occurrence in the 
bearded portion of the neck. It results from what is commonly 
known as an "ingrowing hair." This is caused by irritation of the 
skin so that the hair follicles are closed over the ends of the closely 
shaved beard. When this happens, the hair of the beard grows into 
the skin, causing a slight eruption. Occasionally, a single hair is 
turned about on itself and continues to grow within the follicle. This 
condition, either with or without associated evidences of inflammation, 
results in a cyst which may persist for months, appearing as a small, 
hard, cutaneous nodule the size of a pea. 

Treatment.— When cases show an eruption along the neck at the 
point where the skin is irritated by a starched collar, the patient should 
be advised to shave less closely and to wear a lower collar for a few days. 
In some cases, the short hairs of the beard can be seen turned upon 
themselves with the cut end entering the skin. These should be picked 
out with a needle, and the small wound should be painted with tincture 
of iodine. Men with curly beards find that when they shave closely 
"against the grain" a number of ingrowing hairs result. When the 
true hair-cyst develops, it should be opened under local anesthesia and 
the inside should be swabbed with tincture of iodine. In rare cases, 
hairs several inches in length have been found in these small cysts. 

Branchial Cysts. — The incomplete disappearance of the branchial 
clefts may result in the formation of cysts and sinuses, whose position 



202 



INJURIES AND INFLAMMATIONS OF THE NECK 



corresponds to the location of the clefts; but it appears that the upper 
part of the lateral aspect of the neck just below and in front of the ear 
is likely to show, proportionally, more abnormalities than other por- 
tions of the clefts. They appear as soft, fluctuating tumors, variable 
in size, and usually contain clear, mucilaginous fluid. They are benign 
growths and rarely give symptoms unless subjected to injury. 

The brachiogenous sinuses may occur as 
small slit-like depressions or they may ex- 
tend deeply into the neck. In some cases, 
a small sinus may lead inward to a cyst 
of considerable size. These sinuses usually 
exist for years without giving rise to symp- 
toms. Sooner or later they become infected 
and discharge foul-smelling pus, in which 
case the surrounding tissue will show evi- 
dences of inflammation. 

Treatment.— The cyst and sinus should 
be completely excised. Care should be 
taken to remove the entire cyst wall, which 
is formed of epidermis. Only the com- 
plete removal of this tissue will prevent 
recurrence. In infected cysts, especially if there is inflammation of 
the surrounding tissues, it is better surgery to incise the tumor and 
await the subsidence of the inflammation before attempting removal. 




Fig. 122.— Cyst of the neck 
in a child containing clear 
fluid. 




Fig. 123. — Patent branchial cleft, probe passing into tonsil area. Discharge of mucus, 

one drop in eight minutes. 



Hygroma. — An hygroma of the neck and face is a non-malignant 
congenital tumor, usually situated on the lateral aspect of the neck but 
sometimes extending below the clavicle or into the axilla. It is 
characterized by being a soft, elastic, normal-colored swelling rarely 
interfering with function and varying in size from a small local edema- 
tous patch to a swelling as large as a man's head. It may be sessile 



TUMORS OF THE NECK 



203 



or pedunculated. On section it is found to consist of numerous slightly 
enlarged closed lymph spaces dilated with a serous fluid. These spaces 
may break into each other to form numerous larger lymph spaces, 
multilocular cysts, or a single large cyst often spoken of as a hydrocele. 
The tumors may be situated in the subcuticular tissue, but are more 
often found to invade the deep structures. 

Treatment.— Excision may be carried out where the hygroma is small, 
superficial, or consists of a single cyst; but in the usual type where the 
prolongations invade the deep structures with thin, ill-defined walls, 
radical operations are unsatisfactory and dangerous. Where the 
spaces are large, multiple puncture gives temporary relief. Alcohol 
injections have cured certain cases. Spontaneous cure is frequent. 




Fig. 124. — Hygroma of the right cheek, present since birth. 



Thyroglossal Cysts.- — The thyroglossal duct is an embryonic duct of 
the thyroid gland, passing in front of the thyroid cartilage and the 
thyrohyoid membrane to the hyoid bone, which it may pierce or pass 
posterior to, emptying on the dorsal surface of the base of the tongue. 
Normally, the duct is obliterated and exists only as a thin fibrous cord ; 
but it may persist, discharging a mucoid secretion into the mouth. 
More commonly, only a portion of it persists, the opening into the 
mouth being closed. The retention of the discharge from the lining of 
the duct forms a cyst which may be spherical or elongated, and which is 
periodically subject to attacks of acute inflammation. During one of 
these attacks of acute swelling, the cyst may have the appearance of 
an acute abscess. If this apparent abscess ruptures or is incised, the 
inflammation will subside rapidly, but the discharging sinus persists. 
This sinus, if untreated, may last for years, and is known as a thyro- 
glossal sinus. The usual history of such a sinus is that it heals up and 



204 



INJURIES AND INFLAMMATIONS OF THE NECK 



remains healed for several months or longer, only to break open again 
later on. 

Treatment.— The conservative treatment consists of opening the sac 
and swabbing the entire wall with pure carbolic acid. This procedure 
rarely results in more than temporary relief. 

By far the better plan is complete excision of the cyst wall and any 
remnant of the duct that remains patent. This may develop into a 
much more extensive operation than would be anticipated from the 
external examination, as the sinus is likely to extend upward through 
the hyoid bone to the base of the tongue. As a preliminary to the 
operation, the cyst should be injected with a solution of methylene blue 




Fig. 125. — Two thyroglossal sinuses and small cyst. 



(2 per cent), so that the walls of the sinus can be easily detected during 
the dissection. If the duct passes through the hyoid bone, it should 
be curetted away, and the dissection continued above the bone if 
necessary. If the cyst and sinus have been entirely removed, the 
wound may be sutured without drainage. If even a small portion of 
the sinus remains, the cyst is very likely to recur. 

Tumors of the Thyroid Gland. — Diffuse enlargement of the thyroid 
gland is of common occurrence both in simple and exophthalmic goiter. 
Localized enlargement of the gland frequently occurs either in the form 
of cysts or in a parenchymatous or adenomatous enlargement. These 
conditions are usually spoken of as a goiter, but it would be better to 
limit this term to the diffuse variety, specifying cyst of the thyroid or 



TUMORS OF THE NECK 



205 



adenoma of the thyroid in localized tumors of the gland. Malignant 
adenocarcinoma and sarcoma occasionally occur. 

Diffuse enlargement of the gland may be easily diagnosed by the 
characteristic shape of the tumor. Discrete tumors are likely to be 
confused with branchiogenous or thyroglossal cysts or with tuberculous 
glands of the neck. However, both glands and cysts of the neck, except 
those arising in the thyroid itself, rarely occur in the region of the 
thyroid gland. Besides this, the gland being attached to the trachea, 
always moves during the act of swallowing, whereas other tumors of 
the neck remain stationary. 

Treatment.— Diffuse enlargement of the thyroid gland without other 
symptoms (simple goiter) is a benign growth in its general charac- 
teristics, but often from its size alone it may cause symptoms. Exoph- 




Fig. 126. — Small cyst in a girl, aged eighteen years. Attached to thyroid. 



thalmic goiter is a general disease characterized by diffuse swelling of 
the gland combined with exophthalmos and symptoms of hyper- 
thyroidism. The treatment of these conditions is a problem having 
aspects which are both medical and surgical. Operation is frequently 
indicated, but it has not been agreed definitely as to the type of case 
requiring operation and at what stage of the disease the operation 
should be performed. The discussion of these problems is not permis- 
sable in a book on minor surgery, but will be found in detail in works 
on internal medicine and general surgery. 

The removal of a small cyst or a parenchymatous nodule is a much 
simpler matter. While these tumors are benign, they frequently 
increase in size and cause a disfiguring deformity of the neck. More- 
over, they are particularly likely to undergo malignant degeneration. 
In consequence, it is fully agreed that all such tumors should be 



206 INJURIES AND INFLAMMATIONS OF THE NECK 

removed at the earliest possible opportunity. The operation can 
usually be performed under local anesthesia. After the skin has been 
prepared, an incision is made over the tumor in the direction corre- 
sponding to the natural folds of the neck. This so-called collar incision 
is carried through the subcuticular tissue, all bleeding points being 
carefully ligated. The sternohyoid and the sternothyroid muscles 
may be separated in small tumors or divided in the larger growths, 
thus exposing the capsule of the gland. The capsule of the gland is 
incised and the tumor shelled out. All hemorrhage is carefully con- 
trolled and the dead space in the gland is obliterated by plain gut 
sutures. The capsule is then lightly sutured; the muscles are returned 
to their normal position ; the subcuticular tissue, including the platysma 
muscle, is carefully approximated and sutured, and the skin is closed 
with fine horsehair or fine silk. Drainage is usually unnecessary. 
We have found that the cut portions of the platysma, unless carefully 
united, have a tendency to draw upon and spread the scar. 




Fig. 127. — Lipoma on back of neck. Steady growth for over thirty years. Removed 

under local anesthesia. 

Lipoma. — Lipomata are very common about the neck, where they 
occur most frequently on the posterior or lateral aspects. 

The encapsulated variety, the most common type, begins as a small, 
soft lump, hardly distinguishable from the superficial fat, and gradually 
increases in size until it can be felt as a large mass of soft consistency 
possibly as large or larger than an orange. Although always benign 
lipomata cause considerable inconvenience because of their size, and 
should, therefore, be removed as soon as diagnosed. 

The diffuse form is most frequently seen below and behind the ears 
on each side of the neck. In some cases, the diffuse lipoma forms a 
broad band extending like a collar almost entirely around the neck. 
It may reach a large size, but it is usually less disfiguring than the 
encapsulated variety. 

A third form of lipoma is the so-called intermuscular lipoma. 



TUMORS OF THE NECK 207 

Strictly speaking, it is an encapsulated lipoma composed of many small 
lobules which extend between the muscles. Its dissection on this 
account is very difficult. 

Treatment.— The encapsulated variety is the easiest to remove. If 
the tumor is not too large, local anesthesia is all that is required. The 
incision should be made in the folds of the neck, so that the scar will 
fall into one of the natural folds and hence cause little or no deformity. 
The incision is deepened down to the capsule of the gland which is 
usually very thin. It is important to recognize this capsule which lies 
beneath the subcutaneous layer of fat, as otherwise, the dissection is 
very difficult. After the capsule is reached, it is slit through and the 
tumor is shelled out from within the capsule. In this manner, it will 
be found that the shape of the tumor is more or less lobulated and that 
there are possibly small lobules extending outward from the main 
tumor. All of these lobules should be recognized and removed during 
the operation. As a rule, there is very little bleeding, but occasionally 
a few vessels are cut and require the application of a ligature. After 
the tumor has been removed, plain gut sutures should be so placed 
that, when tied, they will tend to draw together the walls and obliterate 
the cavity. Several such sutures may be required. If this is done, the 
postoperative subcutaneous hematoma is less likely to occur. The 
operation wound is sutured with fine silk or horsehair which, except in 
large wounds, is removed on the fourth or fifth day. 

The diffuse type of lipoma is much more difficult to remove. As 
there is no distinct capsule, it is necessary to remove the tumor widely 
by sharp dissection. In the operation, care must be taken not to 
injure important structures of the neck which may run in close proxim- 
ity to the growth. Indeed, in some cases, important vessels and nerves 
appear to pass through the body of the tumor. After removal, the 
cavity should be more carefully closed than after operation for the 
encapsulated variety, as the removal of a lipoma of this type is always 
associated with considerable hemorrhage. 



CHAPTER VII. 

SPECIAL SURGICAL CONDITIONS OF THE TRUNK. 

In the discussion of the minor surgery of the trunk, only those 
conditions will be dealt with which, because of their frequency or 
character, acquire special significance when located upon the trunk. 
Boils, sebaceous cysts, lipomata, dermatitis, cellulitis, and many other 
surgical conditions occur on the trunk just as they occur elsewhere, 
but as they have already been discussed in detail they will not be 
referred to here. 




Fig. 128. — Traumatic asphyxia following crushing injury. Head, neck and shoulders 
blue-black. Grave dyspnea from infiltration of mucous membrane. Later pneumonia 
and slow recovery. 

CONTUSIONS OF THE TRUNK. 

Contusions of the Chest. — Severe contusions of the chest may cause 
marked shock and even sudden death without apparent injury to any 
of the contained organs. This condition is known as concussion of the 
chest. In addition to the external contusion, the ribs may be fractured 
or any of the contained organs may be injured. Hemoptysis some- 
times occurs without demonstratable lesions of the lung. Injury to 
the lung may be followed after an interval of several days by traumatic 
pneumonia. 



CONTUSIONS OF THE ABDOMEN 



209 



Treatment.— In addition to the treatment of the external contusion, 
treatment should be instituted for shock, if present. In the early 
stages, artificial respiration is sometimes indicated. Pneumothorax, 
hemothorax and rupture of the diaphragm may all occur as complica- 
tions and require treatment. It is wise to keep any person who has 
suffered a severe contusion of the chest in bed for several days, and to 
watch carefully for any indication of internal complications. If 
bleeding into the pleura occurs, the pleura may be aspirated several 
days after the trauma. Ordinary pneumothorax requires no special 
treatment, except rest in bed; but if there is marked dyspnea, an 
aspirating needle may be inserted and the air allowed to escape. 
Suction apparatus is not required for air, but is necessary for the 
removal of serum or blood. 




Fig. 129. — General subcutaneous emphysema resulting from contusion of the thorax. 



Contusion of the Abdomen. — The abdominal walls may be contused 
without injury to the contained viscera. In examining a patient who 
has recently had a serious injury to the abdomen, it is sometimes very 
difficult to determine whether the tenderness is confined to the abdomi- 
nal wall or is a result of injury to a viscus. It is important to remember 
that, immediately after an injury there is little or no pain referred to 
the viscera, even though they may be seriously injured. Only after the 
secondary reaction has set in, does characteristic pain and rigidity 
occur. Rupture of the kidneys, liver, or spleen, or of one of the 
hollow viscera, may occur, or there may be either extra- or intra- 
peritoneal hemorrhage from the torn mesentery. The external evi- 
dences of injury are likely to be very misleading. There may be 
severe internal injury with little or no external evidences, or there 
may be a history of a severe blow to the abdomen with marked ecchy- 
mosis and swelling and no injury to the deeper parts* If the blow has 
14 



210 SPECIAL SURGICAL CONDITIONS OF THE TRUNK 

been expected and the patient has had sufficient time to fix the abdomi- 
nal muscles, there is less danger of internal injury. Unexpected trauma 
with the muscles relaxed is more likely to be associated with injury to 
a viscus. 

Treatment.— A patient who has had a severe abdominal contusion 
without definite symptoms of internal injury should be put to bed 
and kept under close observation. Morphine is advised against, 
because it masks the symptoms. The urine should be examined to 
determine the presence or absence of blood. Inability to void urine 
may indicate a rupture of the bladder or urethra. Free fluid in the 
peritoneal cavity means either internal hemorrhage or rupture of a 
viscus and is an indication for operation. General symptoms of 
hemorrhage, especially when associated with free fluid in the abdomen, 
demand immediate operation. Increasing shock, vomiting, and rest- 




Fig. 130. — Boy, aged nine years, fell from tree, could not pass urine; taken to hospital 
next day, catheterized, bladder emptied, tumor remained; no temperature, no tenderness, 
no other history. Operation. Appendicular abscess found. 

lessness are all symptoms which may indicate internal injury and 
should be carefully watched for. If these symptoms do not make their 
appearance within a few hours, the case may be treated expectantly. 
An ice-cap should be applied to the injured area and small doses of 
morphine given hypodermically to reduce the pain and restlessness, 
due regard being taken of the danger of masking the symptoms of severe 
internal injury. Absolutely nothing is given by mouth, fluids being 
supplied by continuous proctoclysis. 

In mild injuries, the symptoms of shock and abdominal pain usually 
decrease within a few hours, and the patient may be allowed water by 
mouth after twelve hours have elapsed. Such a case should be kept in 
bed, and, if the symptoms are continually decreasing, allowed light 
diet after twenty-four hours. Unless the injury has been compara- 
tively slight and associated with mild local symptoms, the patient 
ghould be kept in bed until the third day or even longer, 



WOUNDS OF THE ABDOMEN 211 

In a second group of patients, symptoms which may be mild immedi- 
ately after the onset become steadily worse. Signs of internal hemor- 
rhage develop with either clear cut or ill-defined local symptoms. 
These cases require laparotomy as soon as possible. Statistics have 
shown that the earlier the operation is performed the greater is the 
percentage of recoveries. 

In the third group, the patients recover from the primary shock 
under the treatment outlined above. The pain grows less and the 
patient looks and feels fairly comfortable. After a period, varying 
from a few hours to a day or longer, the abdominal symptoms become 
more marked. Pain increases, and rigidity, which is apt to be slight 
or absent in the severe cases of the second group, becomes progressively 
more pronounced. The temperature rises and there is an increased 
pulse-rate. In other words, there is a secondary peritonitis. Such 
cases should be operated upon before the peritoneal symptoms become 
too severe. Only the mildest degree of peritoneal irritation should be 
treated conservatively. 

WOUNDS OF THE TRUNK. 

Wounds of the Chest. — Wounds of the chest may open either the 
pleura or the pericardium. The symptoms are those of internal 
hemorrhage, with signs of pneumothorax or hemothorax. As a later 
complication, suppuration may occur either in the pleura or in the 
pericardium. Subcutaneous emphysema is not uncommon. 

Treatment.— If the heart is injured it may be exposed and sutured, 
if the case is seen at once. Ordinarily the facilities for operation are 
not available until several hours have elapsed, and if the patient is 
able to survive as long as this, the probability is that the wound has 
not penetrated the heart and will heal without sutures. Unless 
symptoms of hemorrhage are present it is better not to explore a wound 
of the pleura. The external wound is cleansed by the routine method 
and sutured without drainage. Occasionally, it is advisable to explore 
sufficiently to catch and tie the deep bleeding points, as in a divided 
intercostal artery. It is often very difficult to ligate the intercostal 
artery. In a case seen recently, what was apparently about to prove 
a fatal hemorrhage from a wound of the intercostal artery was pre- 
vented by the use of a silk suture passed by means of a curved needle 
through the skin and intercostal muscle into the pleural cavity and 
out through the intercostal space below, thus including the artery and 
the rib in the loop. A similar suture was passed on the other side of 
the wound and the hemorrhage was thus completely controlled. 

Wounds of the Abdomen. — Wounds of the abdomen have no special 
significance unless the abdominal cavity has been entered. In such an 
event an immediate exploratory laparotomy is strongly indicated. In 
cases of doubt the wound may be enlarged under cocain anesthesia 
until it can be determined whether or not it has penetrated the abdomi- 
nal cavity. If it has penetrated the patient should be sent to the 



212 SPECIAL SURGICAL CONDITIONS OF THE TRUNK 

hospital for immediate operation, if, in the judgment of the surgeon, 
the wound is of such a character that injury to the abdominal contents 
is probable. If the external symptoms of injury are slight, but the 
patient shows the evidence of intra-abdominal hemorrhage, the case 
is one for operative interference. Occasionally a patient is seen who, 
after careful examination shows no local or general symptoms of intra- 
abdominal wound, but who, nevertheless, develops symptoms after a 
few hours or longer. With this possibility in mind, abdominal wounds 
should be kept under observation for several days, until the absence of 
internal injury can be definitely ascertained. In case of doubt, explore 
every abdominal wound. 

SPRAIN OF BACK. 

Under this heading several lesions are rather loosely grouped together. 
They have in common only the fact that following falls or twisting 
movements the back becomes stiff and motion is difficult and painful. 
Some of these cases are true sprains of the vertebral column, while 
others are strains of the muscles or muscular attachments of the back. 
The so-called lumbago is in some cases only a sprain of the back. 

The element of sprain or strain in lifting heavy weights, associated 
with exposure to cold, may cause a very troublesome lumbago which 
is likely to be resistant to treatment. One of the theories of lumbago 
accounts for the condition by a hypothesis which presupposes a tearing 
of the fibers of the muscles of the back, followed by exudation which, 
being confined between the tense fascial planes, causes exquisite pain. 
Another theory considers lumbago as a neuralgia of the nerves, brought 
on by stretching of the nerve fibers in lifting, or secondary to a blow or 
fall. In any case, the distinction is more apparent than real, because 
the treatment of the two conditions is very similar. Most cases show 
tenderness on deep pressure over the muscles and pain on standing or 
bending over. 

A clinically distinct type is sprain of the sacroiliac joint. This may 
be caused by the same traumas which produce other sprains of the back, 
or it may follow parturition. Pain from this condition may extend 
to the lumbar region or down the leg of the affected side, simulating 
sciatica. The diagnosis is made on local tenderness over the sacro- 
iliac joint, and pain on extreme flexion of the leg. 

In the severer cases of back-sprain, pain may persist for weeks or 
months in spite of treatment. There is probably no other condition 
in which it is so difficult to form a reliable opinion as to the probable 
period of disability as in traumatic injuries to the back. 

Diagnosis. — The condition must be differentiated from Pott's 
disease, fracture, and chronic osteoarthritis of the spine. In all of 
these affections the disability is likely to date from an injury to the 
back. The roentgen ray is a valuable aid in diagnosis and should be 
used in doubtful cases. To exclude fracture it is necessary to have 



SPRAIN OF BACK 213 

several views of the vertebral column taken in different directions. 
The character of the bones and the thickness of the surrounding tissues 
make the interpretation of a single plate very difficult. In certain 
cases roentgenographs taken immediately after the accident are nega- 
tive; while those taken two or three months later show a roughening of 
the margins of the bodies of the vertebrae. This appearance is ascribed 
to tearing of the periosteum followed by callus formation. 

Prognosis.— The prognosis in all cases of injury to the back should 
be guarded, for in many cases pain and disability persist for months or 
years. 

Treatment.— Two indications are to be met: (1) The relief of pain; 
(2) the support of the back. 




Fig. 131. — Fracture of the twelfth rib from a blow on the side. Treated for sprain. 

^ Pain may be relieved in the severer cases by rest in bed with the 
application of heat. A hot water-bag or a hot sand-bag usually act 
admirably. Heat, applied by an electric pad or an incandescent 
lamp, acts equally well, in some cases possibly better. Hot turpentine 
stupes or a hot flaxseed poultice may be tried, if moist heat is desired. 
A favorite method of home treatment which brings considerable relief 
is the ironing of the back. To accomplish this the patient lies in bed 
in the prone position, the back is covered with a piece of soft flannel, 
and an ordinary laundry iron, as hot as can be comfortably borne, is 
passed up and down the back. This should be repeated several times 
daily. 

In cases which are less acute the patient is allowed to be up and about. 
Heat, either moist or dry, may be employed as described above, and in 
addition the actual cautery may be used. If the back is carefully 
gone over with the cautery every three or four days the pain and 
tenderness will often be greatly reduced. Aspirin, acetanilide, phenace- 



214 SPECIAL SURGICAL CONDITIONS OF THE TRUNK 

tin, and other similar drugs may be given. Because of the chronicity 
of the condition and the liability to repeated attacks it is never advis- 
able to prescribe morphine. 

Support is obtained by rest in bed or by adhesive-plaster straps so 
applied as to prevent excessive flexion of the lumbar spine. To be 
efficient the straps must be firmly applied well around on the lateral 
aspects and in sufficient quantity to give adequate support. In the 
case of sacroiliac sprain the strapping should be placed lower and 
should extend completely around the body to act as a support for the 
affected joint. In all cases the plaster should be reinforced. Most 
failures in the use of adhesive strapping for the chest and pelvis are 
due to the fact that the straps are not extensive enough to offer any 
real support. The strapping should be worn continuously for several 
weeks, being removed every week or ten days so that the skin may be 
thoroughly cleansed with alcohol and ether, after which the back is 
restrapped. Care should be taken not to apply the strapping until 
the alcohol and ether have completely evaporated, as both of these 
drugs may act as irritants when covered by adhesive plaster. In 
practice it is often better to remove the plaster after the patient has 
gone to bed at night and then restrap the back before the patient gets 
up the following morning. 

HERPES ZOSTER. 

Herpes zoster occurs quite commonly on the thorax and abdomen. 
It begins with acute neuralgic pain and a slight rise of temperature. 
It sometimes follows trauma or exposure to cold, and occasionally 
occurs in what is apparently an epidemic form, attacking several 
members of the same family. The rash appears on the second or third 
day, occurring as a typical vesicular eruption along the course of the 
nerve. Often two or more nerves are involved and the eruption is 
spread over a considerable area. More rarely the disease attacks two 
opposite nerves, making the eruption bilateral. During the early 
stage before the eruption is apparent the condition may be confused 
with intercostal neuralgia, but after the eruption appears the typical 
distribution of the vesicles, corresponding to the cutaneous area sup- 
plied by the nerve involved, makes the diagnosis easy. 

Treatment. — When the pain is severe it may be relieved by the 
external application of dry heat and the internal administration of 
aspirin or phenacetin. Codein or morphine may be necessary. If the 
vesicles do not become infected, the eruption dries up in a few days. 
Therefore, it is advisable to protect the vesicles against traumatism, 
which may cause rupture and render them liable to infection. Pro- 
tection may be secured by a dry sterile dressing; or, what is better, the 
eruption may be covered with a heavy coat of collodion. Drying 
powders may help, and alcohol containing a small amount of menthol 
or carbolic acid will often relieve the pain. The use of the violet-ray 



MINOR OPERATIONS FOR PLEURISY AND EMPYEMA 215 

or the roentgen ray will sometimes give almost instant relief. Oint- 
ments, because they cause maceration of the skin, favor rupture of the 
vesicles and are therefore contraindicated. Internally, potassium 
iodide in large doses sometimes seems to relieve the pain and shorten 
the course of the disease. In the late stages the vesicles may rupture 
and become infected, in which case they should be treated in the same 
manner as any other superficial infection. 



MINOR OPERATIONS FOR PLEURISY AND EMPYEMA. 

Pleurisy, with effusion, and empyema occur frequently after injury 
to the chest or after inflammatory diseases of the lungs. Either may 
occur as a complication of general diseases or secondary to infective 
processes elsewhere. Abdominal suppuration on the right side may 
involve the right pleural cavity through the lymphatics. The diagnosis 
is made upon the physical signs and exploratory puncture of the chest. 

Exploratory Puncture.— For this procedure a large hypodermic 
syringe and a needle about three inches in length are required. After 
the skin has been painted with iodine, the needle is inserted posteriorly 
between the eighth and ninth ribs to a depth of about an inch. Suction 
is made at this point, and if no pus is obtained, the needle is pushed a 
little way further into the pleural cavity and suction again made. In 
this manner the needle can be made to enter for two inches or more. 
If the results are still negative, the needle is withdrawn and inserted 
again at a spot a few inches from the first puncture. Adhesions of the 
parietal and visceral pleura may prevent the withdrawal of fluid, even 
when the needle has been inserted deeply into the chest. A good work- 
ing rule, in cases showing frank physical signs, is not to consider the 
exploratory puncture negative until at least three punctures have been 
made. Ordinarily no anesthesia is required; but in sensitive patients, 
a preliminary cocainization of the point of puncture may be desirable. 
An occasional cause of failure is the presence of pus which is too thick 
to pass through the lumen of the needle. 

Aspiration of the Chest.— In pleurisy with effusion the fluid may be 
withdrawn through a needle with a large bore, the operation being 
known as aspiration of the chest. The needle should be about three 
inches in length and the bore should be moderately large. It is often 
convenient to use the same needle that has been used for exploratory 
puncture, the exploration being followed by aspiration, as soon as the 
fluid is found. Fluid in the pleural sac will not flow from gravity alone. 
Some form of suction apparatus is required. Various forms of special 
apparatus have been devised, the principle of most of them depending 
upon the connection of the needle with a vacuum chamber, the vacuum 
being obtained either by a hand-pump or by an ordinary Sprengel pump. 
If such an apparatus is not available, the simplest way to form a vacuum 
is to take a two- to four-liter bottle with a tight-fitting rubber cork, 



216 SPECIAL SURGICAL CONDITIONS OF THE TRUNK 

pass a short piece of glass tubing through the cork, on the outer side 
of which is attached rubber tubing of the length desired. The aspirat- 
ing needle is attached to the other end of the rubber tubing. The 
needle, tubing, and cork should be sterilized, and the tubing tightly 
clamped near the cork. A few drams of alcohol are then poured into 
the bottle and shaken up so that all parts of the bottle are moistened. 
The surplus alcohol is poured out, the cork is held in readiness, and a 
lighted match is applied to the mouth of the bottle. The alcohol burns 
with a sudden explosion. The cork should be inserted as quickly after 
the explosion as possible. If this procedure is properly carried out, an 
almost perfect vacuum will be formed. As the bottle sometimes 
explodes, it should be wrapped in a towel during the process. 

Should a slow, steady vacuum be desired, the siphon method may be 
used. The apparatus is the same as described above with the addition 
of a second glass tube perforating the cork. This glass tube must be 
long enough to reach to within half an inch of the bottom of the 
bottle. Attached to the other end of the glass tube is a piece of rubber 
tubing about three feet long. The bottle is filled with water and tipped 
so that the water starts to run through the rubber tubing, the free end 
of which is placed in a pan or other receptacle. The water will continue 
to run until a vacuum is formed. By clamping off the siphon tube, the 
vacuum can be interrupted at any time and will resume action when the 
clamp is removed. In the above methods care should be taken that 
a vacuum is formed before the aspirating needle is inserted. Where a 
pump is used, the suction should be tried by inserting the needle in 
sterile water before inserting it into the chest. This precaution is 
necessary owing to the fact that the pump may be wrongly marked 
or the valves may have been reversed during cleaning or sterilizing, 
thereby causing the bottle to be filled with compressed air instead 
of a vacuum. To the authors' knowledge pneumothorax has been 
caused by neglecting this precaution. 

If a large quantity of fluid is present it is better to withdraw only 
about 500 to 600 cc at one time, as the sudden relief of pressure may 
cause alarming symptoms of collapse with or without associated edema 
of the lungs. After the fluid has been evacuated the needle is with- 
drawn and the puncture is closed with a small collodion dressing. In 
inserting the needle an area is chosen where the physical signs indicate 
the greatest accumulation of fluid. This is usually the seventh or 
eighth intercostal space in the region of the posterior axillary line. 
Care should be taken not to injure the intercostal vessels which run 
on the inferior border of the rib, or to direct the point of the needle 
downward into the diaphragm. It is hardly necessary to state that in 
inserting the needle care should be taken not to injure the heart or the 
large vessels of the thorax. If ordinary precautions are taken, the 
point of the needle may be inserted for two or three inches without 
danger of serious injury to the lungs. Local anesthesia is not ordinarily 
required. 



MINOR OPERATIONS FOR PLEURISY AND EMPYEMA 217 

Minor Operations for Empyema.— Thoracotomy, with resection of 
several inches of one or more ribs, is the operation of choice in every 
case of empyema, except possibly the tuberculous form. However, 
in some cases, the patient is too weak to stand this operation, or the 
facilities at hand are insufficient, so that various minor operative 
procedures have been devised. In most cases, they should be con- 
sidered as simply preliminary to resection of a rib. They can all be 
performed under local anesthesia, and are associated with practically 
no operative shock. Simple thoracotomy is the simplest operation. 
After preliminary preparation of the skin and infiltration with 0.5 
per cent novocain solution, an incision is made in the intercostal 




Fig. 132. — Brewer's empyema drainage tube. (Keen.) 



space down to and through the parietal pleura. A rubber tube is 
inserted through this opening, and a large dressing applied. Great 
care must be taken not to allow the tube to slip into the chest, as it 
may easily slip beyond reach and require an extensive operation to 
remove it. Such an accident can be prevented by the use of a safety 
pin, placed transversely through the tube. The wound must be 
dressed daily, and the drainage tube gradually shortened. Irrigation 
of the pleural cavity is usually not advisable. In some cases, this 
procedure will result in a complete cure; but as a rule the opening is 
insufficient and thoracotomy is required. 

Aspiration may also be practised in the same manner as for pleurisy 



218 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



with effusion; but, except for tuberculous empyema, aspiration is far 
inferior to simple thoracotomy. Its use is justified in tuberculous 
empyema in very young children, and as a palliative measure pre- 
liminary to thorough drainage. In tuberculous cases aspiration fol- 
lowed by the injection of 5 to 10 cc of a 2 per cent formalin in glycerin 




Fig. 133. — Brewer's empyema drainage tube in place, held by adhesive plaster. (Keen.) 

solution has been advised. This same plan may be used in inoperable 
cases of empyema which are not tuberculous. The aspiration of the 
pus and the injection of the formalin-glycerin solution seem slowly 
to change the character of the pus to a seropurulent exudate and finally 
to a clear serous effusion which eventually disappears. 

Drainage by means of a catheter inserted through a cannula has 



SURGICAL CONDITIONS OF THE BREAST 219 

also been used in some cases. A trocar and cannula about the size of a 
16 F. catheter are inserted through the intercostal space, and after the 
trocar is withdrawn a catheter is inserted into the chest through the 
cannula, which is then withdrawn. This catheter is left in place until 
the discharge becomes very slight, and is then gradually withdrawn. 
This operation is only rarely curative, but it often serves to relieve the 
acute symptoms until the more radical operation can be performed. 

SURGICAL CONDITIONS OF THE BREAST. 

The most important lesion of the breast is malignant tumor. Every 
non-inflammatory mass in the breast should be looked upon with sus- 
picion, and a careful diagnosis made. All cases, where there is any 
doubt, and those cases which seem to infiltrate, no matter how small 
the tumor, should be turned over to major surgery; while those cases 
that seem to be clearly benign belong properly to minor surgery. 



Fig. 134. — Early carcinoma of the breast in a woman, aged thirty-four years. Note 

beginning retraction of the nipple. 

Other important minor surgical conditions of the breast are abscess, 
fissure of the nipple, simple hypertrophy, and tuberculosis. 

Abscess of the Breast. — Acute mastitis, with or without abscess 
formation, may occur in either sex at any age as a result of trauma. 
In nursing mothers it is frequently seen as the result of infection through 
a cracked nipple. The bacteria apparently extend along the milk 
ducts, forming an abscess at some distance from the nipple. The 
disease begins with pain and induration, which are followed by soften- 



220 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



ing and abscess formation. A few cases go on to resolution without 
breaking down, but as a rule those showing an area of localized tender- 
ness and induration, with an elevation of temperature, finally go on to 
abscess formation. 




Fig. 135. — Acute mastitis of the axillary mammary gland. 

of the axilla. Excised. 



Diagnosed as new growth 



Treatment.— In acute mastitis without abscess formation, cold appli- 
cations or ichthyol ointment may be applied. Nursing from the 
affected breasts should be stopped, and fissures or abrasions of the 
nipple should receive appropriate treatment. A saline cathartic 
should be given to decrease the congestion. If, after a short period, 




Fig. 136. — Acute mastitis of the left breast, non-lactating. 

the condition becomes more acute and there is daily rise of temperature, 

there is abscess formation which requires incision. If the case is severe, 

the child should be weaned at once, and the breasts allowed to dry up. 

Abscess of the breast may be opened in two ways, depending on the 



SURGICAL CONDITIONS OF THE BREAST 



221 



location. A superficial abscess should be opened by a skin incision 
which radiates from the nipple. This direction is important, because 
a radial incision injures the smallest possible number of milk ducts. 
After incision, the wound should be drained in the same manner as an 
abscess occurring elsewhere. 

Retromammary abscesses should be opened by means of a circum- 
ferential incision at the lower margin of the breast. The breast is 
dissected up, and an opening made into the abscess from beneath the 
breast. A rubber tube is used for drainage. 

Intramammary abscesses are often multiple and while they may be 
opened by either of the above methods it is best to open them from 
below. When the indurated area is near the skin and there is distinct 
pus formation a radial incision may be made, but as a general working 
rule all intramammary abscesses should be opened by an incision made 
from beneath the breast. This gives better drainage and leaves a less 




Fig. 137. — Ulceration of the nipple in a boy, aged eight years, following mastitis of 

adolescence. 



objectionable scar. In all cases it is necessry to open widely and to 
keep the cavity open for several weeks, as early healing is almost certain 
to be followed by recurrence. The operation should be performed 
under a general anesthetic, preferably nitrous oxide. 

A semicircular incision about three to four inches long is made through 
the skin just below the fold of the breast. This incision is deepened by 
passing the gloved finger into the wound and up along the line of 
cleavage between the pectoral muscle and the mammary gland to the 
level of the abscess cavity, which is then opened. The tract is then 
enlarged to admit three fingers. Any additional abscess cavity is 
drained in the same manner and all trabecular are broken down. The 
wound is packed with vaseline and gauze; a rubber tube and a broad 
gauze drain are inserted; and dressings and a supporting bandage are 
applied. 

As the inferior fold of the breast is on a level with the lower border 



222 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



of the pectoralis major muscle, care must be taken to avoid the usual 
mistake of carrying the incision up between the pectoralis major and 
the thoracic wall. Should this accident occur, the portion of the 
incision posterior to the pectoral muscle should be abandoned and the 
procedure carried out as above described; for if the abscess cavity is 
drained through the pectoral muscle, the contraction of the muscular 
fibers will close the sinus before the abscess cavity has completely 
healed. 

Chronic Lobular Mastitis. — In this condition there is chronic indura- 
tion of numerous lobules, so that the breast seems to contain numerous 
ill-defined small lumps. It may occur at any age after puberty, and 
is not likely to be painful except at the menstrual periods, at which 
time some of the lumps may be tender and associated with acute 
neuralgic pain. Cyst formation may follow. 




Fig. 138. — -Large cystadenomata of the breast in a girl, aged twenty-two years, develop- 
ing rapidly during a second pregnancy. 



Treatment.— Support of the breasts, with the application of ichthyol 
ointment, seems to have some influence on this condition. Careful 
examination of the pelvic organs and the blood may reveal local or 
general disease, which should receive appropriate treatment. Some 
of these cases are apparently associated with intestinal stasis and 
improve when the intestinal condition is relieved. As cystic degenera- 
tion may go on to malignancy, it is often advisable in chronic cases of 
the severe type to remove the entire breast. 

Tuberculosis of the Mammary Gland. — This condition, occurring 
as a primary lesion, is a very rare disease. Extension from the skin, 
rib, or other contiguous tissue is not uncommon. Tuberculosis of the 
breast may occur at any age after puberty; and, as would be supposed, 
is more common in female breasts. Previous disease, such as acute 
mastitis, or injury, seems to act as a predisposing cause. There are 
two forms of tuberculosis of the breast, the nodular and the confluent, 



SURGICAL CONDITIONS OF THE BREAST 



223 



both associated with little or no pain. During the later stages a cold 
abscess may form and discharge externally. 

Treatment.— In the early stages, if the process is not too extensive 
the lesion may be excised. Where it is more extensive and it is desired 
to save the breast, the patient may be put on general hygienic treat- 




Fig. 139. — Confluent tuberculosis of the mammary gland. 

ment combined with a course of tuberculin. Lactation should be 
avoided, as the increased activity in the gland causes the disease to 
become more active. If these measures fail, complete excision of the 
breast is advised. If the axillary glands are involved, they should be 
dissected out. 




Fig. 140.— Paget's disease of the breast of two years' duration. 

Tumors of the Nipple.— Tumors of the nipple are rare. Benign 
tumors, such as angiomata, fibromata, and papillomata, occasionally 
occur. Sebaceous cysts in and about the nipple, although rare, are 
sometimes seen. Epithelioma and malignant- dermatitis (Paget's 
disease) may be seen in patients during the cancer period of life. 



224 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



Paget's disease begins apparently as a chronic eczema and goes on to 
epitheliomatous changes. It is resistant to treatment, and is probably 
in most cases, if not in all, epitheliomatous from the start. 

Treatment.— Benign tumors should be excised. Epithelioma and 
Paget's disease indicate complete removal of the breast. Of late, 
radium and the roentgen ray have given very satisfactory results in 
the treatment of epithelioma and Paget's disease. 

Benign Tumors of the Breast. — As has already been mentioned, 
many breast tumors are malignant. 

Tumors of the breast connected with the skin, such as papillomata, 
angiomata, and sebaceous cysts, should be treated as similar growths in 
any other part of the body. 




Fig. 141. — Carcinoma of the breast, recurrent. 

It should be remembered that, while small cystic tumors and areas 
of interstitial thickening may frequently be felt in the female breast, 
these are essentially benign and never give rise to symptoms. In the 
atrophied breasts of old age, these small, tumor-like masses are easily 
felt, and must be differentiated from malignant growths. 

Periductal fibromata and fibroadenomata are the most common 
of the benign tumors that require removal. Fibromyxomata and 
cystic adenomata occur less frequently. 

Some authorities say that every benign tumor of the breast is apt to 
become malignant. 

Treatment.— Even when it is decided, because of the slowness of the 
growth or the age of the patient, that a tumor is benign, wide excision 



TUBERCULOSIS OF THE REGION OF THE TRUNK 



225 



should be practised. No tumor of the breast should be dissected out 
or cut into, as after such an operation, should the growth prove malig- 
nant, a cure is practically never obtained, even after the most thorough 
secondary operation. 

Every growth removed from the breast should be sent to the patho- 
logist for examination; and in those cases, where at the time of opera- 
tion a doubt arises as to the innocence of the tumor, a frozen section 
should at once be made. If the report is negative, that is, that there 
are no signs of malignancy, the wound may be closed and treated 
conservatively; but if the report shows evidence of malignancy, then 
the major operation should be at once carried out. 

In the removal of even a small tumor of the breast, a wide excision 
is always advised, as a large cavity or dead space is left. This space 
should be carefully obliterated by sutures. Otherwise, owing to the 
vascularity of the breast, a large blood clot, that is likely to break down 
or become the seat of other trouble, will form. 




Fig. 142. — Bilateral hypertrophy of the breasts in a non-pregnant woman, aged thirty- 
four years, accompanied by symptoms of menopause. 

Hypertrophy of the Breast. — This condition is usually unilateral 
and may occur in either the male or female. One breast becomes 
larger than the other and is likely to be slightly sensitive to pressure. 
The cause of this condition is obscure, but it usually resolves without 
treatment after a period of several months. Ichthyol or belladonna 
ointment may hasten resolution. In some cases, a dry diet with rest 
in bed and the internal administration of iodide of potash may give 
relief. Occasionally the operative removal of the breast becomes 
necessary. 



TUBERCULOSIS OF THE REGION OF THE TRUNK. 

Tuberculosis of the mammary gland has already been described. 
In addition to this, other forms of tuberculosis are fairly common. 
15 



226 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



Bone tuberculosis, occurring in a rib, the sternum, the dorsal or lumbar 
vertebra?, is frequently seen. In addition to this, tuberculous processes 
may occur in the sternoclavicular or sacroiliac articulation. Cold 
abscess of the back, secondary to tuberculosis of the ribs or a tubercu- 
lous empyema, and abscess of the abdomen, secondary to a Pott's 
disease of the spine, are fairly frequent. A detailed description of all 
these conditions would exceed the scope of this book, consequently 
only a few which may properly be classified under minor surgery, will 
be described. The symptoms are similar to those of tuberculosis 
elsewhere, and treatment should always include the general hygienic 
measures for the cure of tuberculosis. Tuberculin treatment may be 
indicated in selected cases. 




Fig. 143. — Tuberculosis of the skin in a boy, aged twelve years, duration eight years. 

General health exceptionally good. 



Tuberculosis of the Ribs. — This begins as a thickening of one rib, 
which is only slightly tender. It is often disregarded for a time. 
After several months the surrounding tissues become involved, and the 
skin may be slightly reddened. Sooner or later fluctuation occurs, 
which indicates the formation of a cold abscess. It may persist at 
this stage for months, but generally there is a steady progression until 
the abscess ruptures and discharges externally. Mixed infection 
usually occurs. The tuberculous pus frequently travels a considerable 
distance between the external and internal intercostal muscles, becom- 
ing subcuticular at the anterior margin of the external intercostal 
muscle near the end of the bony rib. Consequently, though the 
swelling may first become apparent anteriorly, the lesion may be several 
inches away on the lateral aspect of the chest or even posteriorly near 
the spine. The diagnosis rests on local tenderness of the rib at the 
site of the lesion and the roentgenographic findings. 






TUBERCULOSIS OF THE REGION OF THE TRUNK 



227 



Treatment.— Palliative treatment consists of attention to the 
general health and aspiration of the abscess when it occurs. This 
rarely results in cure. Operation, with thorough excision of the 




Fig. 144. — Tuberculosis of the first rib. Draining for eight months. 




Fig. 145. — Upper lesion appeared when patient was six years old; healed after many 
months. Five or six years later middle wound was made to drain abscess; healed after 
three years. Lower wound opened nine years later, and discharged for about one year. 
Roentgen ray, negative; blood, negative. Small piece of gauze found in bottom of wound; 
prompt healing followed removal. 

diseased bone, is preferable. The diseased portion of the bone and 
periosteum should be widely removed and the wound allowed to heal 
by granulation, Frequently, healing is satisfactory until the wound is 



228 SPECIAL SURGICAL CONDITIONS OF THE TRUNK 

nearly closed, from which point it becomes chronic, the sinus persisting 
more or less permanently. Even when the operation has been most 
extensive and every particle of diseased tissue has been apparently, 
carefully removed, there may be a persistent sinus which stubbornly 
resists treatment. The injection of bismuth paste, cauterization of the 
sinus with pure carbolic acid, and curettage under local anesthesia 
may act beneficially. In just this type of case we have found tuberculin 
of greatest benefit. If these measures fail after several months of 
trial, a second operation is indicated. 

Aspiration of a Cold Abscess. — In addition to the ordinary orthopedic 
treatment, tuberculous abscess of the back or abdomen may require 
surgical treatment. As a general rule, incision and drainage of a 
tuberculous abscess result in secondary infection and are inadvisable 
unless the primary focus can be removed. However, the pain due to 
pressure is often so great that surgical measures are necessary. Con- 
sequently, the abscess should be evacuated, and this is best done by 
aspiration with a large needle or small trocar and cannula. The 
contents of the abscess are often of such character that unless a needle 
of very large bore is used, it will become clogged and the operation 
results in failure. A primary injection of cocain or novocain into the 
skin is the only anesthesia required. If the trocar is used, its insertion 
should be preceded by a small skin incision, because the skin offers a 
considerable obstacle to the passage of a moderately large trocar. 
The pus is removed either by pressure on the abscess or, better, by 
aspiration with a large syringe, or suction bottle. The cavity being 
emptied, the cannula may be removed, or half an ounce of 2 per cent 
formaldehyde in glycerin may be introduced into the cavity through 
the cannula. In some cases, iodoform from 2 to 5 per cent may be 
advantageously added to the formaldehyde-glycerin solution. After 
the cannula has been removed the small skin incision should be sutured 
with a single stitch to prevent sinus formation. 

In those cases in which the above solution is used, there is likely 
to be increased pain and swelling for several days after the injection. 
Following this, the abscess becomes smaller and may give little trouble 
for several months. We have at present under our care several 
patients who return every three or four months for aspiration of an 
abscess secondary to bone disease. During the intervals, the patients 
are able to be up and about attending to their work. In all cases it is 
advisable to make cultures from the pus obtained, in order to detect 
secondary pyogenic infection, when it occurs. 

Tuberculosis of the Lymph Nodes. — Tuberculosis of the axillary or 
inguinal lymph nodes may occur either independently (rarely), or in 
connection with tuberculosis of other groups of nodes. The condition 
is very much less common than tuberculosis of the cervical nodes. 
What has already been said in reference to the cervical nodes applies 
equally to the same condition in nodes either in the axillary or inguinal 
regions. 



SURGICAL DISEASE OF THE UMBILICUS 229 

Artificial Pneumothorax. — During recent years artificial pneumo- 
thorax has been advised as a therapeutic measure against unilateral 
pulmonary tuberculosis. It is of value in selected cases for the relief 
of hemorrhage, as a measure intended to secure rest for the affected 
lung, and in cases which are steadily growing worse in spite of medical 
treatment. It will be unsuccessful if there are adhesions between the 
lungs and the chest wall so that the collapse of the lung is prevented. 
Nitrogen, because it is slowly absorbed and non-irritating, is the best 
gas to use. The operation requires a cylinder containing nitrogen, a 
fine needle, and a water manometer connected with rubber tubing to 
the apparatus for the injection of nitrogen. A spot is selected where, 
because the breath and the percussion sounds are normal there are 
probably no adhesions, and the needle connected with the manometer 
is introduced through the intercostal space. If the pleural sac has been 
entered there will be a distinct up and down movement in the manom- 
eter which will register a slight negative pressure. If this does not 
occur, an incision should be made down to the pleura and a blunt probe 
inserted through the puncture to determine if a cavity exists. If one 
is found, the injection may proceed; if not, a new puncture must be 
made. The nitrogen is slowly forced into the pleura, from 300 to 500 
cc being introduced, and the wound sutured without drainage. The 
injection should be repeated daily for several days, and then at intervals 
of three or four days, and finally at three or four week intervals, 
compression being maintained for a year or longer. Incision is 
unnecessary, except at the first operation. 

The extent of compression is shown clearly by the roentgen rays. 
Plates, taken at intervals, will give an excellent record of the progress 
of the compression. If the immediate result is an increase in the general 
symptoms, or, if there is more rapid progress in the other lung, the 
treatment should be discontinued, an aspirating needle being inserted 
to allow the gas to escape. 

SURGICAL DISEASE OF THE UMBILICUS. 

Hemorrhage. — Hemorrhage from the umbilicus may occur in infants 
after the stump of the cord has become detached. Ordinarily, slight 
pressure is enough to stop any bleeding that may occur. When this 
is insufficient, the bleeding-point may be caught in an artery clamp and 
ligated. In rare cases it may be necessary to pass a subcutaneous 
purse-string suture about the bleeding point. The strictest asepis 
should be observed. 

Umbilical Hernia. — Hernia of the umbilicus is extremely common 
in infancy. It is usually first noticed when the child is several months 
old, but may be seen within a few weeks after birth. Pertussis, 
diarrheal diseases, phimosis, and excessive coughing or crying, all 
increase the intra-abdominal pressure and may be followed by hernia. 
The sac may contain intestine or omentum. The tumor rarely becomes 



230 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



large, usually being about the size of a walnut. If reduced and held 
by a small pad fixed in place by adhesive plaster, and kept reduced for 




Fig. 146. — Umbilical hernia, recent. 

several months, the hernia often disappears. It is probable that many 
cases disappear spontaneously, for although very common in infants, 
cases are rarely seen in older children. 

In adults, umbilical hernia is likely to 
occur in individuals who have a large 
amount of abdominal fat. There is a 
fairly common type which is small in size 
and contains omentum. This is likely 
to be present for a long period without 
being recognized. If the patient be- 
comes thinner, the hernia may grow 
smaller and completely disappear. In 
patients who become very fat, the hernia 
may increase in size and reach enormous 
proportions. The mild degree of hernia 
may be successfully controlled by a belt. 
More satisfactory results are obtained 
by early operation. 

Umbilical Sinus. — The persistence of 
a patent urachus may cause a cyst or 
a sinus formation which does not become 
evident until late in life. Depending 
on the degree of closure, one of three 
conditions may arise : (1) A sinus, which 
communicates with the bladder and dis- 
charges urine, may be present when the 
entire duct is patent; (2) a short sinus, 
which discharges only epithelium and 
sebaceous material, may follow from closure of the bladder-end ; (3) a 
cyst may follow closure at both ends with the center remaining patent, 




Fig. 147. — Umbilical hernia in 
a patient, aged eighty-two years, 
of sixty years' duration never 
caused symptoms. Ring would 
only admit finger; very active 
peristalsis. 



SURGICAL DISEASE OF THE UMBILICUS 



231 



Treatment.— In those cases showing a large cyst or sinus extending 
to the bladder, the entire cyst or sinus should be dissected out through 
a median incision. In the less defined cases, where there is only a 
short sinus, it may be swabbed with pure phenol. If this fails to cause 
healing, the sinus should be dissected out under local anesthesia. 
As it may be necessary to open the peritoneum, it is better to be 
prepared to do the larger operation. 

Suppuration of the Umbilicus. — The umbilicus is a common seat of 
inflammation. One type of inflammation is due to uncleanliness and 
irritation from foreign material lodged in the folds of the skin, causing 
a superficial dermatitis. This can be cured by cleanliness and the use 
of dusting powders. In a second type, the umbilicus appears as a 
tender, indurated area, showing evidences of acute cellulitis. Such a 




Fig. 148. — Sinus of the umbilicus. Patent urachus. Chronic eczema. 



condition may be due to various causes. It may be simply a large 
furuncle, following the infection of a hair follicle; it may be a cellulitis, 
following a small abrasion, or it may be an infection of a previously 
unnoticed cyst or sinus of the urachus. A frequent cause of inflamma- 
tion about the umbilicus is seen in children who dig into the umbilicus 
with dirty fingernails. This scratching soon leads to dermatitis, 
eczema, and cellulitis. 

Treatment.— The treatment of the milder cases is the same as in 
dermatitis or eczema. For the severe cases incision may be required. 

If the condition is found to be due to a persistent urachus, the 
tract should be excised after the local inflammation has subsided. 
For some time there may be considerable doubt as to the cause of the 
inflammation; but, if after incision, there is a persistent discharge and 
a tendency to recur, it is safe to consider the condition as secondary to 



232 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



a persistent urachus and to remove the sinus by excision. Very rarely 
a sebaceous cyst in the region of the umbilicus may become inflamed 
and give precisely the same symptoms as a superficial cyst of the 
urachus. However, from a practical viewpoint the differential diag- 
nosis is unimportant, because the treatment in both cases is complete 
excision of the entire wall of the cyst. 

TUMORS OF THE TRUNK. 

Benign tumors, either in the form of fibromata or sebaceous cysts, 
are very common on the back and chest. They present no special 
characteristics. Primary carcinoma and sarcoma may occur on the 
surface of the thorax, back, or abdomen, but, except in the region of the 




Fig. 149. — Papilloma (seed wart) of the back in a man, aged thirty-seven years; rapid 

growth; two weeks' duration. 



breasts, they are very rare and have no special significance. Lipomata 
occur frequently upon the back in the region of the scapulae. They 
sometimes reach an enormous size. The treatment is the same as that 
of lipomata occurring in the neck. 

Keloid. — This is a peculiar fibrocellular outgrowth from the corium 
of skin of the chest or back (less frequently in other parts of the body), 
usually arising from a small scar. It grows very slowly and is slightly 
elevated from the surrounding skin. It is usually irregular in shape, 
slightly reddish or pinkish in color, hard, sharply defined, and may 
be roughly oval in shape. In general appearance, it somewhat resem- 
bles an irregularly shaped scar of recent origin. The surface is shining 
and glistening. This condition is extremely common in negroes, in 
which case the growth is purplish in color. The tumor increases in 



TUMORS OF THE TRUNK 



233 



size very slowly, but there is little or no tendency to spontaneous cure. 
It always arises from a preexistent scar and may be considered as 
hypertrophy of the cicatricial tissue. The growths usually occur in 




Fig. 150. — Numerous fibroma. Palms and soles only areas of the body not involved. 




Fig. 151. — Osteochondroma of scapula in a boy, aged seventeen years. Duration, four 

years. 




Fig. 152. — Typical keloidal lesion of the lip in a Kanaka sailor. Small leprosy lesions 
on wrist. Pathological report on section from lip — leprosy. 




Fig. 153. — Keloidal degeneration of the skin in a man, aged fifty-two years. Duration, 

fifteen years. 



TUMORS OF THE TRUNK 235 

midlife and are rare in childhood or old age. Multiple growths are 
common. 

Treatment.— The treatment of a keloid is most unsatisfactory. 
Excision may be attempted but it almost always leads to a larger 
recurrence, the secondary growth developing from the operative scar. 
However, in spite of this, operation should be tried in those cases where 
the scar is conspicuous and results in a disfiguring deformity. The 
excision should be extensive enough to remove all of the new growth. 

The injection of thiosinamin has been tried by Tousey, Crocker, and 
others, who have reported improvement following its use. A 10 per 
cent solution in alcohol has been used, 10 to 20 minims for each injec- 
tion. This is usually followed by sloughing of the tumor and diminu- 
tion in size. The value of thiosinamin administered orally is problem- 
atic. 

Other methods, such as treatment by roentgen ray and radium, 
have all been recommended. They seem to have a selective action on 
the growth. It has been our custom to use the roentgen ray at once 
after the removal of the tumor, and at frequent intervals for some weeks 
thereafter. In some cases the roentgen ray alone has caused complete 
retrogression of a large keloid. 




Fig. 154. — Desmoid of the rectus sheath. 

Desmoid. — A special tumor peculiar to the abdominal wall is known 
clinically as a desmoid. Some authorities consider it a fibroma showing 
a strong tendency to sarcomatous degeneration; and others consider 
it a sarcoma from the start. Desmoids usually arise from the muscles 
or from the fascia covering them, especially the sheath of the recti. 
This is a rare form of tumor, but it is quite characteristic when it 
occurs. Early and wide removal is the only form of treatment. 

Epiplocele. — This is not a true tumor, but is actually a ventral 
hernia. It deserves special mention here because it may be diagnosed 



236 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



as a tumor and its removal attempted without its importance being 
appreciated. These small hernias occur most frequently in the 
midline, but are not necessarily limited to this region. When they 
occur between the umbilicus and the ensiform cartilage they are 
sometimes called epigastric hernias. They are apparently due to a 
congenital gap in the fascia which permits the protrusion of the 
abdominal contents. There may be a hernial sac containing omentum, 
in which case it is a true epiplocele ; but more commonly there is simply 
a protrusion of a small mass of preperitoneal fat. In the early stages 
the protrusion may be reduced and there is a distinct impulse on 
coughing; but in the late stages it frequently becomes irreducible and 
persists as a hard, rounded mass beneath the skin. When a true 
ventral hernia exists, strangulation of the contents of the sac may cause 
abdominal pain and vomiting; but in the false hernia consisting only 
of fat, the symptoms are entirely local in character. 




Fig. 155. — Midline hernia in the new-born one inch above the umbilical opening, 
lesion caused by adhesive plaster. 



Skin 



Treatment.— In many cases no treatment is required; but if strangu- 
lation occurs, which is rare, operation must be performed, the sac 
removed, and the hole in the abdominal wall closed. In many cases no 
sac will be found, the mass consisting entirely of preperitoneal fat, 
possibly slightly altered by fibrous changes due to chronic irritation. 

Cystic Growths.— A number of superficial cystic tumors are met 
with in the trunk. The commonest are the sebaceous and piloni- 
dal. Rarer forms are: inclusion and dermoid cysts, echinococcus, cyst 
of the urachus, spina bifida, incapsulated hematomas, cystic degenera- 
tion of abarent mammery glands, incapsulated sterile pus pockets, 
foreign bodies, etc. 

Treatment. —The treatment for cysts of the trunk is similar to the 
treatment given for cysts in other parts of the body. In large cysts, 
it should be kept in mind that they may be connected by a pedicle with 
one of the viscera or deep cavities, as an echinococcus cyst of the liver, 



FRACTURES AND DISLOCATIONS OF THE TRUNK 



237 



presented through the chest or abdominal wall, a cyst of the urachus 
still having a patent connection with the bladder. Operations on 
cases of spina bifida are almost certain to become infected and later 




Fig. 156. — Hard, painful tumor of back found to be encysted hematoma beneath sheath 

of left lumbar muscle. 

cause meningitis, therefore, no matter how small and pedunculated 
they are, they should be treated as a major case and only operated on 
under the best operating room technic. 




Fig. 157. — Spina bifida. 



FRACTURES AND DISLOCATIONS OF THE TRUNK. 

Fracture of the Clavicle. — This bone is ordinarily broken by falls 
upon the shoulder. The line of fracture is usually in the middle third; 
but in injuries due to direct violence, the fracture may occur at any 



238 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



part of the bone. Fractures of the outer third, where displacement is 
prevented by the strong ligamentous attachments, are frequently 
overlooked. 

The diagnosis is made upon local tenderness, deformity, false point 
of motion, and crepitus. As the bone is located just beneath the skin, 




Fig. 158.— Fractured clavicle, right, inner third. 

it is extremely easy to diagnose fracture from bony irregularity dis- 
covered by direct palpation. In many patients, it is possible to see the 
fractured ends of the fragments move beneath the skin. In children, 
greenstick fracture is common, in which case, false point of motion and 
crepitus are absent. 




Fig. 159. — Fracture of the clavicle. Not visible in the first two roentgenographs taken. 



Treatment.— If there is no deformity, a simple sling for the forearm, 
or a Velpeau bandage, is all that is necessary. This bandage should 
be changed every five or six days and the treatment continued for about 
three weeks. 



FRACTURES AND DISLOCATIONS OF THE TRUNK 239 

In the use of the Velpeau bandage in children, the bandage should 
be removed at least every fourth day. The tender skin of the child 
is very easily macerated when two skin surfaces are kept in contact 
for a few days. Consequently, before the bandage is applied, the skin 
should be cleansed with alcohol and well powdered with talcum powder. 
Cotton should be placed in the axilla between the arm and the trunk 
and in the flexure of the elbow. If the hand is covered, cotton should 
be placed between the fingers. In short, in all cases, but especially 
in children, it is important never to allow two skin surfaces to remain 
in contact for more than a short period. 

In a recent clinic case, in spite of the above measures, a boy of four 
years, under treatment for fracture of the clavicle, developed an ulcer 
in the flexure of the elbow as a direct result of the application of the 
Velpeau bandage for eight days. The father, who was a foreigner, 




Fig. 160. — Fracture of the right clavicle, faulty union. 

had misunderstood the instructions to return in four days, and remained 
away for eight days. The cotton, which had been placed in the flexure 
of the elbow, had slipped about an inch, and the skin was completely 
macerated and infected, so that the entire area sloughed away and 
required treatment for four months before it was completely healed. 
Ordinarily maceration, if well washed with alcohol and powdered with 
talcum, dries up in a few days. 

When the fracture shows displacement, which can be corrected by 
forcing the shoulders backward, the method of treatment which gives 
best results is rest in bed upon the back, with a small pad beneath the 
shoulders; or, what is better, the arm of the injured side may be allowed 
to hang over the edge of the bed. As may be imagined, this position, 
which must remain unchanged for two weeks, is most uncomfortable, 
and will be undertaken only by young women who desire to avoid even 



240 SPECIAL SURGICAL CONDITIONS OF THE TRUNK 

the slight deformity which may occur after less exacting methods of 
treatment. 

For an ambulatory splint, the Sayre dressing usually fulfils all 
requirements. Two strips of adhesive plaster are necessary, each three 
inches wide and long enough to go once and a half around the trunk. 
One strip is fastened about the middle third of the arm and carried 
across the back and around the chest, drawing the injured arm and 
elbow backward. The second strip starts on the back at the sound 
shoulder, passing down onto the opposite arm below the elbow and up 
along the dorsal surface of the forearm to the sound shoulder. This 
strip has a small hole cut at the elbow to prevent the development of 
pressure-ulceration at that point, and as it is attached anteriorly, the 
elbow is drawn firmly forward and held in this position; as a conse- 
quence of this movement the shoulder is forced back. Cotton is 
applied between the skin surfaces as mentioned above, and a light 
roller bandage is applied about the arm and trunk. 

Other methods, such as a figure-of-eight bandage across the back, 
and plaster of Paris supports, have been devised. Results are seldom 
better than with the Sayre dressing, which is easily applied and requires 
little attention. Its disadvantage lies in the fact that the skin of 
children and of some adults becomes easily irritated by the adhesive 
plaster. It should be inspected at least every four days, and, even in 
adults, should be removed and reapplied after eight or ten days. The 
irritation of the skin by the adhesive plaster is apt to be so severe, 
especially in summer, as to require the removal of the plaster. In a 
recent series during the summer months its use had to be given up in 
about 50 per cent of the cases. The Moore bandage may be used as a 
substitute for the plaster. 

Recently the French literature has contained reports of a new 
method. The patient is kept in bed in the supine position with the 
injured shoulder at the edge of the bed, the arm, extended at right 
angles, resting on a chair placed beside the bed. The weight of the 
arm draws the shoulder out and back, bringing the fragments into good 
position. This method has been used by us in a few cases with excel- 
lent results. 

In certain fractures, manual reduction is possible, but, because of the 
character of the displacement, the fragments are not held in position 
by any form of dressing. In these, open reduction and suture of the 
fragments is indicated. 

Fracture of the Sternum. — Direct blows upon the chest may result 
in fracture of the sternum. If there is displacement, the upper frag- 
ment is usually displaced posteriorly. The diagnosis is made from the 
history, the local tenderness, and bony irregularity, if it exists. 

Treatment.— In fracture with displacement an attempt at manual 
reduction should always be made. This is carried out by having the 
patient lie on his back across a narrow sand-bag, thus causing hyper- 
extension and disengaging the overriding of the fragments. The 
anterior fragment is then pressed back into normal alignment. 



FRACTURES AND DISLOCATIONS OF THE TRUNK 241 

In certain cases that resist manual reduction no further attempt at 
reduction is justifiable, if: 

1. The displacement is slight. 

2. The deformity is not marked. 

3. The patient is aged. 

4. The fracture is accompanied by serious internal injuries. 

If manual reduction fails, reduction can always be secured by 
traction. There are two methods of reduction by traction, both of 
which should be carried out under the strictest surgical technic. In 
the first method, a sharp or blunt hook is inserted through a small 
puncture wound in the skin and engaged beneath the posterior frag- 
ment, the body being hyperextended as in the procedure for reduction. 
The posterior fragment is then drawn back into place. In some cases 
it is found necessary to use two hooks, one for each fragment. In the 
second method, a longitudinal incision is made over the line of fracture 
and the fragments are pried back into position. Any fragment inter- 
fering with reduction is removed. General or local anesthesia may be 
used in both methods. 

After reduction a padded basswood splint, 2x8 inches, is laid over 
the sternum and is held in place by adhesive plaster strapping, which 
encircles the thorax, thus limiting costal breathing as much as possible. 
Owing to the possibility of concurrent intrathoracic injury, the patient 
should be kept in bed for the first five or seven days. 

Where the direction of the line of fracture is such that the fracture 
persistently recurs, the question of operative procedure naturally 
arises. Certain cases can be held in position by one or more small 
finishing nails driven obliquely through the fragments. As the sternum 
is so superficial, this can be carried out without incising the skin, thus 
avoiding scars which are objectionable in the upper sternal region in 
women. In other cases an incision is made over the site of the fracture 
exposing the fragments, which are then reduced and held in place by a 
Lane plate, or drilled and sutured with wire or kangaroo tendon. 
Dressings are applied and the chest is strapped, as after reduction. 

Fractures of the Ribs. — The ribs are nearly always broken by direct 
violence from a blow or a fall. The fracture is usually single; but 
simultaneous fracture of two or more ribs, or fracture of one rib at two 
separate places, may occur. Occasionally a rib may be fractured by 
muscular violence in coughing. 1 

As most of the pain of this fracture is due to the associated pleurisy, 
and as this pleurisy rarely becomes evident before the third day, the 
ordinary history obtained is so characteristic as to be almost patho- 
gnomonic of a fractured rib. The surgeon is told that, about three 

1 This cause is apparently more common than is ordinarily supposed. We saw five 
cases in one winter, all due to coughing or sneezing. The diagnosis was confirmed by 
roentgen rays. There is seldom any displacement in cases of this type, which are appar- 
ently frequently diagnosed as intercostal neuralgia or pleurisy. Strapping with adhesive 
plaster for ten days or twq weeks relieves the pain, which is seldom as severe ^s in fracture 
due to direct violence, 
16 



242 



SPECIAL SURGICAL CONDITIONS OF THE TRUNK 



days before, the patient fell and injured his side, but in spite of the 
pain he had continued working until after two or three days the pain 
became so severe that he was obliged to stop, and that now the pain is 
severe on coughing or laughing and increased by deep breathing. The 
latter symptoms are symptoms of pleurisy, which is apparently caused 
by the reparative reaction in the parietal pleura. Given a patient 
who has a non-penetrating injury to the chest several days before 
complaining of typical pleuritic pain referred to the same spot, the 
diagnosis of fracture of the rib is practically certain, even without the 
corroborative objective symptoms which are usually present. 




Fig. 161. — Fracture of twelve ribs, six on each side. Patient walked to clinic; slight 

discomfort. No dyspnea. 

The objective symptoms are localized tenderness at the point of 
fracture, pain referred to the site of fracture on firm pressure against 
the sternum, and, rarely, crepitus or pleuritic friction-rubs heard with 
a stethoscope over the broken rib. 

Although fractures of the ribs are very common, dangerous complica- 
tions rarely occur. There are, however, three complications which 
should always be kept in mind. They are: (1) Laceration of the 
intercostal arteries with hemorrhage into the pleura (hemothorax); 
(2) wounds of the lung with escape of air into the pleura (pneumo- 
thorax) ; (3) wounds of the lung with escape of air into the subcutaneous 
tissue (subcutaneous emphysema) - 1 



1 Blood crepitus must not be confused with air crepitus, 
persistent and usually more extensive. 



The latter is much more 



FRACTURES AND DISLOCATIONS OF THE TRUNK 243 

Treatment.— The most satisfactory method of treatment is fixation 
of the injured ribs by adhesive plaster. Strips are placed about the 
chest from the neighborhood of the fourth or fifth rib downward to the 
tenth rib, extending from a point two or three inches from the midline 
of the back on the sound side, across the midline of the back around 
the injured side of the chest, and across the midline to a point approxi- 
mately anterior to the posterior end of the strip. That is, the strapping 
extends about the injured side of the chest and about three inches upon 
the uninjured side, both in front and behind. The strips are put on 
one at a time at the end of expiration and tight enough to exert firm 
pressure but not seriously to embarrass respiration. In a few cases, 
the patient will suffer much more pain when the chest is tightly 
strapped, in which case the strapping should be loosened but not 
removed. After the chest is strapped (three 3-inch strips of adhesive 
are sufficient), a circular bandage is wound about the chest and left 
on until the adhesive is firmly attached. In fractures of the upper or 
lower ribs, the adhesive should be placed a little higher or lower, but 
it is not absolutely necessary to cover the injured rib in order to relieve 
pain. Limitation of movement on the affected side is the measure 
which causes the diminution of pain. 

On account of the possibility of dangerous complications and for the 
comfort of the patient, it is well to advise rest in bed during the first 
week. Should complications occur, they should receive appropriate 
treatment. 

Fracture of the Costal Cartilages. — The costal cartilages are most 
commonly fractured at, or near, the junction of the rib and the cartilage, 
and the accident is most likely to occur in adults past middle life. The 
seventh and eighth are the cartilages ordinarily fractured. The 
symptoms resemble those seen in fracture of the ribs, except that 
displacement is more likely to occur. 

Treatment.— Reduction is sometimes very difficult. Extension of 
the back, forced drawing back of the shoulders, or deep inspiration 
may all be tried. After reduction, the adhesive strips, as just de- 
scribed under fracture of the ribs, are applied. In some cases, where 
displacement tends to recur, a hernial truss, so placed as to restrain 
the projecting fragment, has been found of value. Operation is rarely 
required, the final result being good even where reduction has not been 
complete. In women, where the deformity would be a constant source 
of annoyance, attempts should be made to reduce the displacement 
under general anesthesia. The writers treated one case by driving two 
small wire nails through the skin into the sternum at the point of 
fracture. 1 By this means the bone could be held in place without the 
necessity of a large scar which is often as objectionable as a bony 
deformity. 

1 A thin wire nail with a small head, ordinarily called a "finishing" nail, was used. It 
was driven obliquely through the line of fracture, including one fragment anteriorly and 
the other posteriorly. The head of the nail was forced through the skin and removed 
through a minute incision about the eighth day. Practically no scar resulted. 



244 SPECIAL SURGICAL CONDITIONS OF THE TRUNK 

Fracture of the Vertebrae. — What has already been said in reference 
to the cervical vertebrae applies equally well to fracture in the dorsal 
and lumbar regions. The surgeon should be on the watch for cases of 
fracture of the spine which have been undiagnosed. It is not uncom- 
mon to have a patient walk into the hospital a week or more after an 
accident, and to find that he has an unsuspected fracture of the spine 
(and this applies to the body of the vertebrae as well as to the more 
fragile processes), although his only symptoms have been pain and 
stiffness of the back. 

The diagnosis is usually based upon the roentgenographic findings, but 
the warning must be emphasized against accepting a negative roentgen- 
ray finding as proof of the absence of fracture. Plates should be taken 
in both diameters and at several angles, before they are considered 
final. The ordinary practice of taking roentgen-ray negatives of the 
spine only in the antero-posterior diameter has led to frequent errors 
of diagnosis. During the last two years we have seen several cases of 
fracture of the spine easily seen in lateral roentgenographs which had 
been diagnosed as sprain because there was no fracture seen in the 
antero-posterior view. 

Fracture of the Pelvis. — While fracture of the pelvis, like fracture 
of the vertebrae, is usually a very serious injury associated with high 
mortality, the roentgen ray has taught us that there exist many cases 
which have been previously unrecognized, and that the condition is 
not necessarily associated with marked disability. It is possible for 
a patient to be up and about even with a complete fracture of the pelvis 
with marked displacement. Patients who after an injury, have per- 
sistent pain referred to the pelvis, should be carefully roentgen rayed 
before fracture is excluded. 

Fracture of the pelvis may involve any bone. It is most common 
in the region of the obturator foramen, and may be complete or incom- 
plete. The complete fractures are usually the more severe and likely 
to be associated with rupture of the bladder or urethra, or other 
injury to the pelvic viscera. Cases suspected of fracture should be 
kept in bed under careful observation. Hematuria or anuria may 
indicate rupture of the bladder or urethra and require operative 
interference. Severe injuries to the pelvis require the care of an 
expert surgeon under the best hospital conditions. Uncomplicated 
cases recover after a few weeks' rest in bed. Persistent pain, possibly 
due to secondary adhesions, is not uncommon. 

Fracture of the Crest of the Hium. — The crest of the ilium may be 
broken by direct violence. If the fragment is small, the patient 
complains of pain on moving the trunk, and tenderness on pressure. 
Ecchymosis is likely to be extensive, and usually the fragments can be 
moved with the fingers, causing crepitus. 

Treatment.— The treatment consists of rest in bed and adhesive- 
plaster strapping to limit the movement of the attached muscles By 
manipulation of the muscles attached to the pelvis, the fragment may 
be drawn into position and held there by sand-bags. 



FRACTURES AND DISLOCATIONS OF THE TRUNK 245 

Fracture of the Spinous Process of the Ilium. — The anterior-superior 
spinous process of the ilium may be broken by muscular action while 
running or jumping. This is a distinct clinical entity, and should be 
recognized when it occurs. The cases reported have been in youths 
eighteen or nineteen years of age, the history being a sudden sharp 
pain while running or jumping, causing the patient to fall to the ground. 
After a few minutes he is able to walk about, but the pain continues. 
The symptoms are local tenderness and pain when the sartorius muscle 
is contracted. 1 In some cases the piece of bone torn away is very small, 
being but a portion of the muscular attachment. 

Treatment.— The treatment consists simply of rest, if there is no 
displacement. When the displacement is considerable, suture of the 
fragment into its correct position is the indicated treatment. With 
either method of treatment, the patient should remain in bed for at 
least three weeks. 

Fracture of the Coccyx. — The coccyx is usually broken by falls or 
kicks or in parturition. If the injury is received on the tip, a com- 
paratively slight blow may result in fracture. Extensive ecchymosis 
is rather characteristic of the lesion and it may extend in both directions 
over the gluteal regions and upper thighs. 

The diagnosis rests upon local tenderness and false point of motion 
with crepitus. These last two symptoms are obtained by inserting 
the index finger in the rectum and grasping the bone between the 
thumb and finger. 

As most cases are not seen until long after the injury when the 
fracture is healed, reduction is impossible. These cases present 
themselves suffering from severe pain on sitting and defecation and 
persistent neuralgic pains in the thighs and legs which may be severe 
enough to constitute sciatica. These symptoms are grouped under 
the rather flexible term — coccygodynia. On examination the coccyx is 
found to be displaced anteriorly, laterally, or posteriorly. 

Treatment.— Under a general anesthetic an attempt should be made 
to correct the displacement. This can usually be accomplished in 
recent fractures. In old fractures, where the tissues have become 
adjusted to the deformity, reduction will be found impossible. In 
these cases removal is indicated. 

Dislocation of the Clavicle. — The clavicle may be dislocated either 
at its sternal or acromial end. In most cases the sternal end of the 
clavicle is displaced upward, or upward and forward. At the acromial 
end the most frequent dislocation seen is incomplete dislocation upward. 

Diagnosis.— The diagnosis is easily made upon examination, the 
end of the clavicle being felt distinctly beneath the skin. 

Treatment.— To reduce the deformity, the shoulder is forced back- 
ward and outward, while at the same time pressure is made against 

1 In the experience of the writers the offending strain has been apparently due to 
muscular action exerted through Poupart's ligament rather than the action of the sar- 
torius muscle. 



246 SPECIAL SURGICAL CONDITIONS OF THE TRUNK 

the projecting bone. After reduction, the arm should be fixed to the 
side, and the forearm carried in a sling for two or three weeks. An 
additional support is gained by adhesive straps so arranged as to 
make pressure directly upon the displaced end of the bone. 

If the displacement tends to recur, it may be necessary to hold the 
bones in place by a periosteal suture. In the hands of the writer, 
permanent reduction has been easily obtained in dislocation of the 
sternal end of the clavicle, but dislocation at the acromial end has 
practically always recurred, so that it is his practice to advise operation 
in every case showing the latter lesion. 

Dislocation of the Costal Cartilage. — This condition is very rare. 
The point of dislocation is at the junction of the sternum with the 
costal cartilage. A more frequent condition is the subluxation of the 
sternal end of the tenth rib. This moves with respiration, and in some 
people the sensation is so unpleasant that excision of the end of the 
cartilage is required. 

Treatment.— If dislocation of the other cartilages occurs, the treat- 
ment is reduction by direct pressure and fixation with adhesive straps. 

Dislocation of the Sternum. — Dislocation of the sternum resembles 
fracture of the sternum and is usually the result of severe and crushing 
injuries to the chest. The type most commonly reported is dislocation 
of the manubrium forward. 

Treatment.— Reduction is accomplished by bending the trunk back- 
ward and making pressure upon the projecting edge. Even if the 
deformity persists, there is little or no disability. Fixation with a 
wire nail may be carried out in the same manner as described under 
fracture of the sternum and costal cartilages. 

Dislocation of the Coccyx. — This injury is closely related to fracture 
of the coccyx. Both occur from the same causes— childbirth, falls 
upon the buttocks or astride a bar or projection. Usually the injury 
is a fracture-dislocation with the bone displaced forward, the projecting 
tip pressing against the rectum. As a result, defecation is painful, 
urination frequent, and the patient may have pain radiating down the 
thighs. In some cases there is severe pain on coughing or sneezing, 
and the patient is unable to w r alk or sit without pain. 

Treatment.— The treatment consists of reduction. The index finger 
is introduced into the rectum, the bone is forcibly grasped between 
the rectal finger and thumb, and if the displacement is anterior, the 
bone is forced downward and its upper extremity is forced outward 
by angulating the bone forward and forcing it downward and backward 
with the index finger. If the displacement is posterior, the coccyx 
is bent back upon the sacrum and driven downward and forward by 
the thumb. 

The dislocation tends to recur, and as it is impossible to arrange 
any form of fixation apparatus, reduction may be necessary every three 
or four days. If the dislocation recurs frequently and causes dis- 
comfort the bone should be removed. 



CHAPTER VIII. 

FRACTURES AND DISLOCATIONS OF THE HAND AND 

ARM. 

FRACTURES ABOUT THE SHOULDER. 

Injuries in the region of the shoulder may cause fracture of any of 
the bones of the shoulder-girdle. Fracture of the clavicle is most 
common, constituting in the neighborhood of 60 per cent of all fractures 
about the shoulder; fractures of the scapula make up about 10 per cent; 
the rest being fractures of the head, neck, and humerus. Gross frac- 
tures are usually readily recognized, and their appropriate treatment 
is found in books on major surgery. There are, however, a few frac- 
tures which may be confused with simple contusion of the shoulder 
which require special mention. In all cases of severe injury to the 
shoulder, a roentgen ray should be taken. 

Fracture of the Coracoid.— This may occur as a result of muscular 
action. It may be diagnosed when pressure upon the tip of the coracoid 
causes deep-seated pain. A similar pain is felt when the arm is 
voluntarily adducted against resistance, thereby putting the attached 
muscles upon the stretch, and when the arm is held firmly and attempts 
made to flex the forearm against resistance. 

Treatment.— The treatment consists in rest of the shoulder and 
elbow-joints by means of an appropriate bandage. If there is much 
separation it may be necessary to suture the fragments. 

Fracture of the Acromion.— In fracture of the outer end of the 
acromion there is likely to be very little displacement and little loss of 
function. Localized tenderness along the line of fracture and pain on 
abduction of the humerus are the principal symptoms. This condition 
is sometimes mistaken for subdeltoid bursitis, but the location of the 
bony tenderness should easily differentiate the two conditions. 

Treatment.— Rest of the shoulder-joint is the only treatment neces- 
sary, unless there is displacement, in which case the arm is bandaged 
with a second roller of Desault. 

In both of the conditions mentioned above the roentgen-ray results 
are likely to be negative, even in the presence of definite fracture. 
Especially in the region of the scapula negative roentgen-ray findings 
should not be allowed to outweigh the clinical evidence. 

Fracture of the Body of the Scapula.— This is due to direct violence. 
Pain is severe when the shoulder is moved in such a way as to rotate 
the shoulder-blade. The vertebral margin and the spine may be 
palpitated to determine bony irregularity. If there is not much 
displacement, the fracture may be overlooked. 



248 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

Treatment.— The treatment consists of the application of a shoulder 
cap and support of the arm with a Velpeau bandage. 

Fracture of the Neck of the Scapula.— This condition must be differ- 
entiated from dislocation of the shoulder. There is a flattening of the 
shoulder and the acromion is unduly prominent. There is a lump in 
the axilla which can be easily reduced but at once recurs. The coracoid 
moves with the humerus. 

Treatment.— A shoulder cap should be applied over the shoulder and 
a pad placed in the axilla. The arm is bandaged to the side, the elbow 
being supported by a third roller Desault bandage, so that the elbow 
is drawn upward and acromion is pressed downward. 




Fig. 162. — Fracture of the neck of the humerus with rotation of the head. 

FRACTURE OF THE HUMERUS. 

Impacted fracture of the anatomical neck of the humerus may 
masquerade as an ordinary traumatic synovitis of the shoulder. As 
the two conditions are usually associated, the diagnosis rests upon the 
severity of the symptoms and the roentgenographic findings. The treat- 
ment is limited to immobilization of the joint and early measures for 
the restoration of function. 

Fracture of the Greater Tuberosity.— This injury is much more 
common than is ordinarily believed and is frequently mistaken for 



FRACTURE OF THE HUMERUS 



249 



dislocation of the shoulder. This mistake arises because attempts to 
bring the elbow across the chest, in an effort to place the hand upon 
the opposite shoulder, causes severe pain which usually prevents the 
movement from being completed. Once the injury is suspected the 
diagnosis is simple. There is localized tenderness over the point of 
fracture, and pain on attempts at external rotation. A characteristic 
symptom of the fracture is the loss of active abduction of the arm, 
while at the same time, the patient is able to hold the arm abducted 
at an angle of 90 degrees when the arm is moved passively to that 
position. In other words, while the patient is unable to abduct the 
arm because of pain, he is able to hold it in full abduction against 
gravity if the movement of the arm to this point is made by the surgeon. 
This is explained by the fact that abduction is started by the muscles 
attached to the greater tuberosity, while it is completed by the deltoid. 

The roentgen ray is likely to be unsatisfactory in this fracture, it 
being often necessary to take several pictures before one is secured in 
the proper axis to demonstrate the fracture. 

Treatment.— The treatment consists of immobilization of the 
shoulder- joint with the humerus in external rotation. If there is 
considerable displacement of the fragment, which is rare, open opera- 
tion may be advised. 




Fig. 163.— Fracture of the surgical neck of the humerus, simulating dislocation. 

Fractures of the Surgical Neck of the Humerus.— Fractures of the 
surgical neck of the humerus are recognized by the localized pain and 
the failure of the head to turn when the elbow is rotated. If the upper 
fragment is grasped in such a way that the fingers are pressed into 
the bicipital groove between the tuberosities, and the elbow gently 
rotated, the failure of the head to share in the movement of the shaft 



250 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

can be easily detected. Usually crepitus can be felt accompanying 
the motion of the shaft. 

Treatment.— The tendency is for the muscles to draw the lower 
fragment upward and inward while the upper fragment is abducted 
and rotated externally. Consequently, reduction should be made by 
traction with the arm abducted to 90 degrees and slightly rotated 
outward. This manipulation may succeed in causing interlocking of 
the fragments, so that the arm may be returned to the side and fixed 
with an ordinary bandage or a plaster shoulder cap. 

If the displacement tends to recur, we have the choice of two methods 
of procedure. Either the arm may be put in abduction by means of a 
plaster cast (and this is the method of choice in children), or the 
continuous traction may be applied with the arm abducted. When 
there is marked displacement, it is necessary that the patient be 




Fig. 164. — Recurrent fracture of the left arm in Paget's disease. 

confined to bed in order to get the best results; but when the over- 
riding is slight, a form of ambulatory splint usually fulfils all require- 
ments. It is made by applying a plaster splint to the inner side of the 
arm from the axilla to the wrist, and on the outer side a wide molded 
splint from above the shoulder, forming a cap, downward on the outer 
side of the arm to the olecranon. Traction is secured by means of 
weights hung on the forearm as close as possible to the flexure of the 
elbow, while the hand is supported by a sling which passes around the 
wrist. A pad is usually placed between the arm and the chest to insure 
slight abduction. 

A modification of this dressing, which has some advantages, consists 
in ending both the external and internal splints just above the elbow 
and applying moleskin plaster strips along the two lateral surfaces of 
the arm in the same manner as for Buck's extension. The ends of the 



FRACTURE OF THE HUMERUS 25l 

plaster hang below the elbow when the wrist is supported by a narrow 
sling. They are used for the attachment of a weight which thus pulls 
directly upon the lower part of the arm. This acts only while the 
patient is erect, either sitting or standing. Theoretically, he should 
have this traction continued during the night, but practically, the 
tension upon the muscles during the day is enough to overcome a 
considerable degree of overlapping. During the war the use of the 
Thomas splint was followed by very satisfactory results in fractures 
of this type. The arm is abducted to 90 degrees, and the splint applied. 
Traction is secured by the use of moleskin plaster and weights, or, what 
is better in ambulatory cases, by an elastic band from the end of the 
traction strips to the cross-bar of the splint. In the modified Thomas 
splint the ring portion of the splint is on a swivel, so that the arm may 
hang at the patient's side without disturbing the traction. By the 
use of this type of splint, traction may be kept up both day and night. 

If the Thomas splint is left on for a long time, the elbow and hand 
may become very stiff. It has been found that if fairly firm traction 
is exerted for the first forty-eight hours, it can be gradually diminished, 
so that in about a week it may be dispensed with and the arm placed 
in a more comfortable position. Early massage and motion of the 
hand and elbow will prevent stiffness. 

Fracture of the Shaft of the Humerus.— Fracture of the shaft of the 
humerus requires the same treatment as fracture of the surgical neck 
when it occurs in the upper third. Fracture occurring lower will do 
well under the plaster dressing above described, except that abduction 
is not required. The application of traction, to correct overriding, is 
even more necessary than in the fractures occurring in the upper part 
of the bone. The use of the Jones' traction humerus splint, which is a 
modified Thomas splint so arranged that the arm is held at the side and 
the forearm supported with the elbow at a right angle, is probably 
the most satisfactory form of ambulatory splint. Traction is secured 
by strips attached to the arm and passing to the angle of the splint. 
While the patient is up the traction may be secured by weights. Dur- 
ing the night rubber bands may be adjusted so as to maintain the 
traction secured during the day. 

Severe comminuted and compound fractures of the humerus should, 
as a rule, be confined to bed and treated by suspension and traction. 

Fractures of the Lower Extremity of the Humerus.— Fractures of the 
lower extremity of the humerus are among the most troublesome of all 
fractures, both as regards diagnosis and treatment. Owing to the fact 
that swelling of the soft parts is usually early and extensive, the bony 
landmarks are obliterated. For the same reason, as well as because 
of the fact that the joint is held partially flexed, the roentgen-ray 
examination leaves much to be desired. According to the older 
classifications, the fractures were either of the epicondyles, or T-, Y-, or 
V-shaped fractures. The roentgen ray has taught us that this classi- 
fication is entirely arbitrary, and that almost every conceivable type 



252 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

of fracture can occur in this portion of the bone. Transverse fractures 
and longitudinal fractures are both of fairly common occurrence, while 
both comminuted and incomplete fractures are frequently seen. 

In examination it is important to decide whether the joint still 
retains some of its bony support, as in fracture of only one condyle; 
or is freely movable on the shaft of the bone, as in transverse and 
T-fractures. 




Fig. 165. — Fracture of the lower third of 
humerus. 



Fig. 166. — Transverse fracture of the 
humerus. 



Treatment. — In fractures without gross displacement of the lower 
end of the bone, the fragment should be manipulated in order to 
get it as near into position as possible, and the elbow fixed with 
a plaster splint at an angle of 90 degrees, the forearm being 
in midpronation. In transverse fractures and those of the trans- 
verse type, the tendency is for the lower portion of the bone 
to be displaced forward and upward. Reduction is accomplished 
by traction on the elbow with the forearm in midflexion, the 
manipulation being similar to that employed in reducing a dis- 
location of the elbow, which usually causes the two fractured sur- 



FRACTURE OF THE HUMERUS 



253 



faces to engage and remain in position. The elbow is then fixed in 
position by means of anterior and posterior plaster splints extending 
from the upper arm to the wrist, and the hand is held in a sling. 
Unfortunately, there is, in a comparatively large number of cases, a 
tendency for the displacement to recur in spite of a satisfactory applica- 
tion of the splints. It has been advised that these fractures be put up 
in acute flexion to prevent displacement. After reduction, the elbow 
is flexed to about 45 degrees and fixed by the application of a light, 
posterior plaster splint, the wrist being supported in a sling. In stout 
persons, where pronounced swelling is expected, this position is not 
without its element of danger, due to the interference with the circula- 
tion at the elbow. In children, who 
are particularly prone to this fracture, 
there is little or no danger of constric- 
tion, and the end-results are apt to be 
especially gratifying. 

In all cases early massage and pass- 
ive motion is indicated . Except where 
the tendency to displacement is very 
marked, the splints should be removed 
on the third day, light massage begun, 
and the joint given very slight passive 
motion. Every second or third day 
thereafter the process is repeated, the 
massage and passive motion being pro- 
gressively increased, and the splints 
being reapplied after such treatment 
during the first two weeks, after which 
the splints are discarded and the arm 
is carried in a sling for two weeks or 
longer. 

The prognosis for final result in 
fracture about the elbow should al- 
ways be most guarded. Healing is, 
of course, almost certain but there 
may be a slight, moderate or complete 

loss of function. There are two complications which are commonly 
seen as after effects. The first of these, angular deformity, is due to 
the healing of the bones at an angle, and as a result the bone may be 
bent either forward or backward or to the side. When the lower frag- 
ment is bent inward, the normal carrying angle may be obliterated. 
If this deformity causes severe pain r or there is marked interference 
with function, refracture or osteotomy may be advised. 

The second bad effect is limitation of motion at the joint. This may 
result in some cases from fibrous adhesions, which may be broken apart 
by forcible movement of the joint, the pain being prevented by general 
anesthesia, preferably nitrous oxide, Occasionally callus formation 




Fig. 167. — Lower four inches of 
humerus absent as a result of an 
accident. Patient, a teamster. 
When he grips with the hand, the 
forearm ascends. When he relaxes 
grip, the arm drops about four 
inches. A very useful flail-joint. 



254 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

interferes with the movements of the joint. In these cases, the joint 
gradually regains a certain percentage of the lost motion after the 
callus has become absorbed three or four months later. Where there 
is interference with motion due to bony deformity, the joint shows 
little improvement from month to month. In such cases, operation 
should be advised, and the bone should be chiseled away so as to allow 
free motion of the joint. 

One of the results of war surgery was the use of early active motion 
in joint injuries. 1 In cases of fracture of the elbow-joint the patient 
was advised to move the joint actively from the first. This method is 
still under trial. In compound fractures, speaking of war wounds, 
Blake advises suspension. This, he says, allows for slight movement 
and thus diminishes the chance of ankylosis. If suspension is not 
available, he advises the use of a double gutter-splint, with a joint at 
the elbow, so that movement is permitted. 

Separation of the Lower Epiphysis of the Humerus.— Separation of 
the lower epiphysis of the humerus is not unusual. The lower extrem- 
ity of the bone is movable in the shaft. The bone may be felt as a 
projection in front of the joint, and the injury mistaken for dislocation. 
This condition occurs in children, generally before the eighteenth year. 
Unless properly reduced, the growth of the bone will be interfered with. 

Treatment.— Reduction is usually accomplished if the elbow is acutely 
flexed in Jones' position. It should be held in this position for about 
two weeks. If the roentgenographs show that this position does not 
place the epiphysis in its proper relation to the shaft of the humerus, 
reduction should be tried under anesthesia. If this is likewise unsuc- 
cessful operative reduction is advisable. 

Fracture of the Olecranon.— Fracture of the olecranon is usually 
transverse at the base of the olecranon process. It may, in some cases, 
be displaced upward an inch or more through contraction of the triceps 
muscle. The superficial situation of the ulna at this point makes for 
an easy diagnosis, the line of fracture showing as a distinct depression 
in the bone and the fragment being easily felt and more or less freely 
movable. The patient is able to extend the forearm in the ordinary 
position of the arm; but extension is impossible when the arm is rotated, 
so that the forearm must be extended against gravity. This symptom 
is rare except in fracture of the olecranon and rupture of the triceps 
muscle. 

Treatment.— The treatment depends upon the amount of separation 
of the fragments. In some cases where they are closely approximated 
with no tendency to displacement, as is usually the case in fractures due 
to direct violence, the arm may be placed in a right-angled splint for 
two or three weeks, with the usual attention to passive motion and 
massage. 

When the injury is due to muscular violence, the separation is likely 

1 Willem's treatment has been described in detail elsewhere. 



FRACTURE OF THE HUMERUS 255 

to be marked, usually half an inch or more, and the treatment is 
correspondingly complicated. 

In non-operative treatment, an anterior splint is applied to the 
extended arm, preferably a molded splint, combined with crossed strips 
of adhesive plaster above the olecranon so applied as to draw it down- 
ward. In addition to this the triceps muscle is given daily massage 
always toward the elbow, the idea being to prevent its contraction 
and the consequent separation of the fragments. The splint is left 
on for from one to four weeks depending on the degree of the dis- 
placement. If there is still marked displacement at the end of four 
weeks only slight further improvement can be hoped for. 

The operative treatment is applicable to those cases in which the 
displacement is sufficiently large to interfere with function. While 
it is difficult to give exact figures, it is safe to say that a separation of 
one-eighth of an inch rarely, or never, causes serious interference with 
function of the elbow, and that a separation of half an inch or more is 
practically certain to weaken the joint. In the case of a laborer, 
operation for a displacement of more than one-quarter of an inch is 
amply justified; while for the desk-worker, non-operative treatment 
may give perfectly satisfactory result in cases where there is a separa- 
tion of nearly half an inch. 

As it is impossible for separation to occur without the laceration of 
the thick lateral expansions of the triceps muscle, the operative treat- 
ment should include the suture of these torn ligamentous bands. Two 
lateral incisions are made, and the torn edges are isolated and sutured 
with interrupted sutures of chromic gut (No. 1), after having washed 
out the blood-clots from the joint-cavity with saline solution, and 
approximating the fractured surfaces of the bone. If an additional 
suture is required, a heavy chromic suture (No. 2 or 3) may be passed 
transversely through the tendon of the triceps muscle just above the 
olecranon and through a hole bored in the ulna just below the line of 
fracture, the suture completely surrounding the fractured olecranon 
and in a lateral plane. The suture is tied, the skin incisions are closed, 
and the elbow is fixed in a position of slight flexion. In this operation 
it is important to secure good exposure of the lateral tendinous expan- 
sions and to suture them neatly and strongly, after which the fracture 
may be treated as a tenorrhaphy, for when the tendon is healed, func- 
tion will return even if there is only fibrous union of the bone. Massage 
is given early, and passive motion is made fairly free after the first ten 
days. The patient is allowed to use the arm for light work after the 
third week, but he is warned not to extend the elbow against resistance 
for six weeks or longer. 

Fracture of the Coronoid Process.— In dislocation of the elbow, 
fracture of the coronoid process is a fairly frequent complication. It 
rarely occurs as an isolated lesion. 

Treatment.— It is treated by fixation, with the elbow in midflexion 
for a period of two weeks, accompanied by the usual passive motion and 



256 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

massage. After the removal of the splints, the arm is carried in a sling 
for two weeks longer, after which functional use is allowed. Operation 
is rarely indicated. 

Fracture of the Head of the Radius.— This is usually caused by 
falls upon the palm, the fracture being due to the impaction of the head 
of the radius against the capitelum of the humerus. Pain, referred 
to the elbow-joint when pressure is made upon the palm, and localized 
wincing tenderness over the head of the radius on direct pressure, are 
the characteristic symptoms. The local tenderness may be easily 
demonstrated by firm pressure on the head of the bone, just below the 
capitelum. Pressure at this point causes severe pain when the forearm 
is rotated. The treatment consists in fixation of the elbow-joint at a 
right angle for about two weeks. Passive motion and massage are 
begun early and continued until there is complete restoration of 
function. 

FRACTURE OF THE BONES OF THE FOREARM. 

Under this heading may be included fractures of both bones and 
isolated fractures of the shafts of the radius and ulna. They are most 
common in the middle and lower thirds of the bones, and make up about 
6 per cent of all fractures. In ambulatory practice, such fractures are 
frequently seen because they occur from what are apparently only 
slight injuries. In the region of the forearm, gangrene and ischemic 
contraction following fractures have been frequently noted. The 
cause of this is not clear. Possibly the location of the blood supply 
in a shallow trough-like formation of bone and fascia may render it 
especially liable to compression, with consequent injury to the limb. 
Many cases of gangrene are undoubtedly due to the use of circular 
splints too tightly applied. In fractures of this region the necessity 
for caution and watchfulness cannot be too strongly urged. 

Treatment.— Reduction of fracture of both bones should be made by 
manipulation by the surgeon, while an assistant makes strong traction 
in the long axis of the forearm. Owing to the possibility of cross- 
union, care should be taken not to make lateral pressure which would 
tend to press the bones together. If the fracture is transverse and the 
broken ends of one bone can be made to engage, the other bone will 
usually be sufficiently reduced to heal firmly. In a few cases of oblique 
fracture the overriding immediately recurs, requiring some form of 
continuous traction. 

In ordinary cases, the bone is held sufficiently firm by anterior and 
posterior wooden splints in a position of mid pronation. The splint 
should be long enough to extend from the elbow to the base of the 
fingers, and should be applied so as to overlap slightly the lateral 
surfaces of the forearm. This has two advantages: (1) It prevents 
lateral pressure which would tend to cause cross-union ; (2) it prevents 
all danger of constriction of the forearm, the bad effects of which have 



FRACTURE OF THE BONES OF THE FOREARM 



257 



already been mentioned. After the acute swelling has begun to 
subside, the so-called "sugar tongs" plaster splint may be used. A 
single plaster splint is made about twice the length of the forearm. 
With the elbow bent and the forearm placed in midpronation, the 
center of the moist splint is bent around the elbow and the inner portion 
carried along the flexor surface of the forearm, and the outer in the same 
manner along the dorsal surface. This is bandaged in place, and when 
hard it is a convenient splint, having little weight and being easily 
removed for massage and passive motion. 




Fig. 168. — Roentgenograph of a cross- 
union of the radius and ulna. Loss of 
rotation. 



Fig. 169. — Roentgenograph of same 
case as shown in Fig. 168. Cross- 
union removed; rotation restored. 



The position of midpronation is chosen because it is the position in 
which the forearm naturally falls across the chest and the position 
which is the most useful to the patient, should the function of pronation 
be completely lost. 

Fixation in complete supination has long been urged, because it is 

claimed that the interosseous space is widest in complete supination. 

This difference is more apparent than real, for the interosseous space 

in the position of midpronation is nearly, if not quite, as wide as 

17 



258 



FRACTURES AND DISLOCATIONS OF HAND AND ARM 



incomplete supination. In fractures of the radius above the insertion 
of the pronator radii teres, the strong pull of the biceps draws the upper 
fragment into a position of complete supination, and it is urged by some 
surgeons that, in these cases the forearm should be supinated to 
correspond with the upper fragment. Even in cases of this latter 
type, the position of midpronation ordinarily gives as good functional 
results as the much more uncomfortable one of complete supination. 
It is well for the surgeon to keep this tendency to rotation of the upper 
fragment in mind, for it is possible that exceptional cases may require 
complete supination in order to secure the proper reposition of the 
fragments. 




Fig.* 170. — Fracture of the lower end of the ulna. 



The use of an interosseous pad, which is a pad about six inches long 
and the size of a lead pencil or a little larger, has also been advised as a 
method of preventing cross-union. If care is used not to exert too much 
pressure upon the soft parts, this pad may be placed along the anterior 
or posterior surface of the forearm beneath the splint, in which case 
it will exert a limited influence toward the prevention of cross-union. 

At the end of the first week when the swelling has begun to subside, 
the wooden splints may be exchanged for anterior and posterior 
molded plaster splints, which are much lighter and more comfortable 
for the patient. These are worn, except when removed for massage, 
until the end of the fourth week, when the anterior splint is removed 



FRACTURE OF THE BONES OF THE FOREARM 259 

and the patient allowed to use the hand to a limited extent. After 
six weeks the splints should be permanently removed, and function 
allowed up to a limit corresponding to the apparent strength of union. 
If union is not firm (and it is not uncommon to have a degree of motion 
at the point of fracture which is distinctly appreciable to the examining 
hand), the patient should be encouraged to use the arm within certain 
prescribed limits, because limited functional use of the part is the best 
stimulus to bone repair. 

In speaking of the mechanical treatment of war fractures of the fore- 
arm, Blake advises treatment of compound fractures of the forearm 
by rest in bed with suspension or traction, secured by the use of a bent 
Thomas splint. For ambulatory patients the Murray modification 
may be used, in which case the lower segment should be made slightly 
elongated so that traction can be applied. Blake advises treating all 
war injuries involving fracture of the forearm and particularly those 
of the radius with the hand in full suspension. When the patient is 
able to be up and about, he advises the use of the Sinclair splint. 
Active motion of the fingers is to be encouraged. 

While cross-union is rare in simple fractures of the forearm, failure 
of union is very common. This is sometimes due to the interposition 
of muscular tissue between the ends of the bone, but is probably more 
often the result of prolonged fixation of the bones in faulty position. 
Many of these cases will be cured by massage combined with the 
functional use of the forearm. For the few cases where the non-union 
persists, operation with the insertion of an autogenous bone-graft 
gives the best results. 

Fractures of the Forearm in Children.— While Colles' fracture is 
the usual fracture seen in adults, fracture of both bones of the forearm 
is the ordinary fracture seen in children. In Colles' fracture the line 
of fracture is commonly from one-half to three-fourths of an inch from 
the styloid process, running in a generally transverse direction across 
the bone to the ulnar margin, the tip of the ulna usually being fractured 
and slightly displaced. In children such a fracture is very uncommon; 
the ordinary trauma, such as would result in Colles' fracture in adults, 
results in a fracture either of the radius alone or of both bones. 

The records of the surgical out-patient department of the Vanderbilt 
Clinic show that during the year there were 65 fractures about the 
wrist-joint, of which 15 occurred before ossification of the lower radial 
epiphysis. These 15 cases, which represent injuries in patients of 
from three years to twenty years of age, include only 1 case which 
may be classed as Colles' fracture. (This was a fracture of the wrist 
occurring in a chauffeur eighteen years of age.) Most were either high 
fractures of the radius with greenstick fracture of the ulna or complete 
fracture of both bones. 

Skillern has published a paper in which he describes complete 
fracture of the lower third of the radius with greenstick fracture of the 
ulna. He found 32 of a series of 100 cases of fracture of the forearm 



260 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

in children were fracture of the lower third of both bones, and 13 of 
these cases were transverse fracture of the radius with greenstick 
fracture of the ulna. He believes the invariable cause of this particular 
lesion to be a fall upon the hand while in motion, the fracture being 
"a resultant of the action of gravity with momentum." The line of 
fracture is high, and the ulna is fractured at about the same level as 
the radius. Most of the cases were between nine and fourteen years of 
age. 

From our material it was apparent that the common fracture about 
the wrist in children before puberty is fracture of both bones, and not 




Fig. 171. — Fracture of both bones of the forearm in a child, equivalent to Colles' fracture 

in an adult. 



fracture of the lower end of the radius, as in adults. After puberty, 
the various fractures about the wrist and the lower end of the forearm 
are similar to those occurring in adults, with the exception of the 
epiphyseal separation, which occurs most frequently from the thirteenth 
to the fifteenth year inclusive. It is usually caused by a fall upon the 
palm with the hand extended. On account of the deformity, many 
cases are treated for a time as a dislocation of the wrist. It should be 
remembered that dislocation of the wrist is extremely rare, while 
epiphyseal separation is relatively common. 

Treatment.— In treatment of fracture of both bones in children, 
overcorrection of the deformity must be emphasized. If this move- 



FRACTURE OF THE BONES OF THE FOREARM 



261 



ment causes a greenstick fracture to become complete, no harm has 
been done; but the intentional completion of every greenstick fracture, 
as has sometimes been advised, is in our opinion seldom indicated. 
The arm is put up in the position of overcorrection and allowed to 
remain in splints for about three weeks. Massage and passive motion 
are seldom required in children, because adhesions are rare and complete 
return of function is the rule. 

When there is extensive overriding, the reduction of which is unsatis- 
factory, some form of the traction apparatus is indicated; or, in a few 
cases, open operation may be required. 

In separation of the lower radial epiphysis, accurate reduction must 
be accomplished to prevent subsequent deformity and interference with 
growth. Once reduced, the epiphysis tends to remain in place, if 
supported by a light splint. After two weeks the splint may be 
removed and the weakened portion of the bone may be supported by a 
leather wristband or adhesive straps. 

Epiphyseal Sprain.— Epiphyseal sprain is the name given to a par- 
ticular form of traumatic injury at the location of the epiphyseal line. 
It is evidently a partial subluxation of the epiphysis, which immediately 




Fig. 172. — Colles' fracture with marked posterior displacement. 



follows after the trauma slips back into place. Examination shows 
the localized line of tenderness at the epiphyseal line, with slight swelling 
over the region of the injury. Roentgenographs are usually negative, or 
at the most show only a slight irregularity at the epiphyseal line due to 
the detachment of a small fragment of bone or a strip of periosteum. 
Most of these cases are unrecognized and recover perfectly without 
treatment within a few weeks. During this period, support with 
adhesive straps, to prevent further displacement, is all that is required. 
Colles' Fracture.— As has already been mentioned, this is confined 
almost entirely to adult life. While the line of fracture usually passes 



262 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

more or less in a transverse direction across the lower end of the radius, 
and the lower fragment is tilted backward and upward, innumerable 
variations of the line of fracture and the displacement may occur. 
Impaction is often present, and comminution of the lower fragment is 
of not uncommon occurrence. The easily recognized silver-fork 
deformity, when present, makes the diagnosis in typical cases com- 
paratively simple. Associated fracture of the tip of the ulna occurs 
in about 30 per cent of the cases, but can seldom be diagnosed except 
by roentgen ray, and has no bearing on the treatment. 




Fig. 173. — Colles' fracture with lateral displacement. 



Cases with displacement may be mistaken for dislocation of the wrist. 
If we remember that dislocation of the wrist occurs so seldom that it is 
a surgical curiosity, the mistake is not likely to be made. On the other 
hand, cases with slight or no displacement are frequently mistaken for 
sprain. The location of the tenderness, if carefully mapped out, is 
sufficient to differentiate fracture from sprain. In sprain, the tender- 
ness is located over the joint at some part of the ligament; while in 
fracture, the line of tenderness is at some distance from the joint. 

Treatment.— Colles' fracture is so exhaustively treated in the larger 
books on major surgery that a complete discussion of the treatment is 
not required in a work on minor surgery. It is desirable, however, to 
call attention to certain special points in the accepted manner of 
treatment. 

Impacted fracture, if in good alignment, need not be broken up. 



FRACTURE OF THE BONES OF THE FOREARM 263 

The increased trauma incident to the breaking up of the impaction 
causes marked reaction, which is likely to be followed by stiffness of 
the arm and hand. This is of little consequence in young adults, for 
function soon returns under appropriate treatment; but in patients 
over fifty years of age, this stiffness may persist for months or years. 
In patients still older (over sixty), it is often better to permit a moderate 
degree of deformity to persist in an impacted fracture, rather than to 
attempt reduction. 

Except in the above cases, reduction, preferably under anesthesia, 
is indicated when there is any deformity either with or without impac- 
tion. Complete reduction is necessary, for it is especially inadvisable 
in this fracture to expect the pressure from the splints to accomplish any 
appreciable result toward reduction. 

There have been various splints advised in the treatment of Colles' 
fracture, all of which claim certain points of superiority. Thus, 
splints have been advised which keep the wrist in extreme flexion, on 
the theory that the pull of the posterior ligament will prevent displace- 
ment of the fragment; and in the same manner and for similar reasons, 
a position of ulnar flexion is supposed to counteract the displacement 
of the head of the ulna. 

According to Stimson, these positions are wrong in theory and the 
results are disappointing. A suitable splint is one that immobilizes 
the radius and carpus in the position of complete reduction and allows 
free movement of the fingers. 

Anterior and posterior wooden splints, extending from the upper 
part of the forearm to the metacarpophalangeal joint, are well suited 
to the purpose. If there is a tendency to backward displacement, a 
pad of folded gauze may be placed on the anterior splint just above the 
line of fracture, and a second pad on the posterior splint over the lower 
fragment of the radius. A modification of this splint places a roller 
bandage at the palmar end of the anterior splint, so that the wrist is 
slightly extended and the hand grasps the bandage, the posterior 
splint being made to end at the wrist. The splints are held on with 
strips of adhesive plaster, and a bandage, which leaves the fingers free, 
is applied. After the second day the patient is encouraged to move the 
fingers freely, and the forearm is lightly massaged. The massage is 
continued daily, and after a week the patient is allowed slight use of 
his hand, the splint remaining in place. After the third week, the 
splints may be removed and functional use of the hand allowed. Hard 
work should not be permitted for at least six weeks, but moderate use 
of the hand is encouraged. 

Lighter and more convenient splints may be made of plaster of Paris. 
They are placed in the same location as the wooden splints, but are 
molded to the forearm and hand. They permit fairly complete action 
of the fingers, so that with their support it is possible for the patient 
to resume his occupation (if it requires no special strain upon the 
injured bone) after ten days or two weeks. 



264 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

The circular plaster splint is a very convenient form of splint for 
this injury and for the following fracture. We have applied it as rou- 
tine in the following way : A wick of muslin bandage about three inches 
wide is folded three-ply, or one inch, and is laid upon the bare arm, 
being tucked between the middle and ring fingers extending up on the 
front, or palmar surface, of the hand and forearm to the elbow, where 
it is held temporarily by a piece of adhesive. During the time the 
dressing is being applied and until it is hardened, it is well to have an 
assistant hold the hand, making slight traction to keep the bone in 
proper position. The hand and forearm with the muslin strip are now 
covered with four or five layers of muslin bandage, and over this a 
thin plaster bandage is applied extending from the metacarpophalangeal 
joints to the upper fourth of the forearm. During hardening the splint 
may be molded wherever local pressure is required. As soon as the 
plaster has set (from ten to thirty minutes) , the end of the wick between 
the fingers is grasped and a small hole is cut through the outer layer. 
The point of a pair of bandage scissors is introduced in this hole and, 
using the wick as a guide, the plaster and underlying bandage are split 




Fig. 174. — Col'.es' fracture complicated by compound fracture of the radius, showing 
the result of treatment. Splint removed and arm massaged for two weeks. Function 
good. Slight stiffening on removing splint. 

up the anterior surface of the hand and forearm. When the cutting 
is complete, both ends of the wick are grasped in the hands and the 
wick is removed. This maneuver proves that all layers have been cut, 
and the use of the wick makes it easy to run the scissors beneath the 
bandage without cutting or pinching the skin. After removing the 
wick, the circular splint should be reshaped with the hands and a gauze 
bandage placed about the splint to keep it clean and to hold it in place. 
Plaster split in this manner is not apt to become too tight. The arm 
should be seen daily for several days, and then the splint may be 
removed for massage and motion. After two or three weeks, in 
ordinary cases, the plaster can be removed and replaced by a few turns 
of adhesive, split, after application, by the use of a similar wick. The 
adhesive should always be split before the patient leaves the surgeon's 
office. A few turns of gauze bandage over the adhesive will keep it 
in place and prevent its becoming soiled. This support is worn for 
about three weeks. 

Chauffeur's Fracture of the Radius. — Chauffeur's fractures are caused 
by the sudden and violent reversal of the cranking lever during the 
manual starting of the motor. 



FRACTURE OF THE BONES OF THE FOREARM 265 

This force may act upon the radius in two ways: (1) By means of 
impaction transmitted through the palm in the region of the thenar 
and hypothenar eminences; (2) by means of hyperextension of the hand 
transmitted to the radius through the strong anterior ligaments of the 
wrist-joint. Theoretically, the cases due to impaction would show 
features identical with, or approaching, the lesions of Colles' fracture; 
while hyperextension would cause lesions having more of the charac- 
teristics of the so-called extension fractures of the lower end of the 
radius. 

If a study is made of a series of roentgen rays of chauffeur's fractures, 
it is seen that in very few of them is the lesion that of the typical 
Colles'. In only one case of a recent series was the line of fracture 
as high as that seen in Colles' fracture. Most show fractures running 
near, or into, the lower articular surface, with little or no deformity. 
Impaction, when present, is very slight. Displacement is absent 
in some cases, while in others there is a slight amount of rotation back- 
ward of the lower fragment through its transverse axis. 

These cases correspond almost exactly to the type of experimental 
hyperextension fracture in the cadaver, and are, consequently, probably 
due to the same cause. 




Fig. 175.— Colles' fracture of the chauffeur type ; recent. Marked silver-fork deformity. 

Symptoms.— The symptoms due to the fracture vary according to the 
lesion; the slightly oblique fracture which passes into the joint (the 
most typical form of chauffeur's fracture) often showing very slight 
loss of function and only moderate pain. In most cases there is little 
or no bony deformity, and false point of motion is obtained only with 
great difficulty. 1 Some chauffeurs have been able to drive their cars 
for several hours after the injury. One patient drove his care for ten 
days and only finally came to the clinic because of his inability to crank 
the motor. The wrist is usually swollen and shows areas of ecchymosis, 
and the physician is called upon to exercise considerable ingenuity 
in distinguishing the injury from simple sprain. However, if we 
remember that a sprained wrist which is severe enough to cause the 
patient to seek medical advice is rather rare because most get well 

1 As there is no displacement of the fragment, it is a mistake to try to elicit false point 
of motion in cases of chauffeur's fracture. 



266 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

without medical care, and if we further remember that this fracture 
may occur without deformity, the diagnosis becomes comparatively 
simple. Given the history of the case, an injury to the wrist when the 
crank "kicks back," there is only one symptom necessary for the 
diagnosis, and this is the typical, localized tenderness just above the 
wrist-joint. This has been called "wincing" tenderness, and is easily 
obtained by direct pressure over the line of fracture. It is most marked 




Fig. 176 




Fig. 177 

Figs. 176 and 177. — Two views of sprain fracture of the wrist. 

bone torn away by ligaments. 



Note small pieces of 



upon the second and third days, and persists until the third week or 
even longer. If this line is carefully marked out with a blunt instru- 
ment, it will commonly be found to run close to the articular margin, 
and the tenderness will be found both on the palmar and dorsal aspects 
of the bone. In sprain, due to the same cause, the tenderness would 
be more marked anteriorly. 



FRACTURES OF THE CARPUS 



267 



It need hardly be stated that in this particular fracture a roentgeno- 
graph is especially advisable. The line of fracture is often indistinct, 
and unless the plate is so taken that all the finer details are brought out, 
the lesion may easily be overlooked. 

Treatment.— The treatment of chauffeur's fracture does not differ 
from that of the ordinary type of fractures in any of the essential 
details. Naturally, those cases showing linear fracture without 
displacement do not require reduction. In the exceptional cases, 
where there is considerable displacement, the fracture should be re- 
duced and the condition dealt with in the same manner as in Colles' 
fracture. The milder cases should receive early massage and passive 
motion, and never require fixation for a period longer than two weeks. 
In these cases, a posterior molded plaster splint has been found most 
satisfactory, the splint extending from the metacarpophalangeal 
joint to a point on the upper third of the forearm. This permits a 
limited use of the hand for light work after the tenth or twelfth day. 
The light circular plaster splint, as described above, may be used. 

FRACTURES OF THE CARPUS. 

These fractures, which are comparatively rare, are frequently 
mistaken for sprained wrist. The localization of the tenderness and the 
roentgen ray usually make the diagnosis clear. The scaphoid is the 
bone most frequently fractured. Next, in frequence, are the semilunar 
and the os magnum. Fracture of the other bones seldom occurs. 




Fig. 178. — Fracture of the scaphoid, with hematoma. 

Scaphoid.— This is usually fractured by a strong blow on the ball 
of the thumb when the hand is extended. The line of the fracture is 
transverse, and the characteristic symptom is tenderness below the 
styloid process of the radius, best elicited by pressure in the triangular 
depression between the extensor tendons of the thumb. In some 
cases, the proximal fragment may be felt displaced forward on the 
palmar aspect of the wrist just below the lower extremity of the radius. 



268 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

Dislocation forward of the semilunar bone is a frequent complication 
of this condition. 

Treatment. —The treatment of these cases is unsatisfactory. Impair- 
ment of motion at the wrist is the rule, and a good functional result is 
the exception. This possibly is because fracture of the scaphoid is 
rarely recognized until several weeks after the accident. Stimson 
advises, in cases seen early, immediate immobilization for about a 
month without passive motion or massage. In old cases, the treat- 
ment is massage and the various mechanical measures for the relief 
of. stiffness. 

In cases seen later, where there is no improvement as a result of the 
use of mechanical treatment, the fragment of bone can be removed 
through a half-inch incision between the tendons of the extensor 
communis digitorum and the extensor carpi radialis brevior. In a 
few cases it has been necessary to remove the entire first row of carpal 
bones in order to secure functional improvement. 

Fractures of the Semilunar and the Os Magnum.— Fractures of the 
semilunar and the os magnum, as well as of the other bones of the 
carpus, occasionally occur. Except for the localization of the tender- 
ness, the symptoms resemble those accompanying fracture of the 
scaphoid. The peculiar grouping of the bones of the carpus and the 
thickness of the overlying parts make the exact character of the injury 
doubtful, even Avith the aid of the roentgen ray. 

Treatment.— The treatment is identical with that of fracture of the 
scaphoid. Owing to the complexity of the articulations about the 
wrist, early operation is not advisable even when the loose fragment 
can be distinctly seen in the roentgenograph. 

The pisiform may be fractured by the contraction of the flexor carpi 
ulnaris, the plane of the fracture being at right angles to the line of 
force. In the commonest form of the fracture of the pisiform— that 
caused by direct violence— there is no displacement of fragment, owing 
to the fact that the bone is surrounded by dense tendinous tissue. 
The diagnosis is based upon the local tenderness, slight crepitus, and 
pain on the contraction of the flexor muscles. No special treatment is 
necessary. Functional recovery is the rule. 

Fracture of the Metacarpals.— The common and easily recognized 
metacarpal fracture is a transverse fracture of the shaft. This injury 
is most often due to indirect violence, as that resulting from a blow 
with the clenched fist; but may result from direct violence, as com- 
monly occurs in crushing injuries to the hand. Compound fractures, 
a result of direct injuries of the dorsum of the hand, are of frequent 
occurrence because of the unprotected location of the bones. 

The third and fourth metacarpals are said to be most frequently 
broken, but the injury may occur to any one of them, and simultaneous 
fracture of two or more is not uncommon. The usual displacement 
is angular, with the apex directed either forward or backward. Owing 
to the bony support of the adjoining bones, lateral displacement is very 



FRACTURES OF THE CARPUS 



269 




Fig. 179. — Exostosis of ulna and fractures of the fifth metacarpal bone in a patient 
reporting many fracture from slight causes. 




Fig. 180. — Boxer's fracture of the metacarpal bone. 



270 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

rare. Overriding occurs in oblique fractures and is often difficult to 
overcome. 

While the usual fracture of the shaft is easily recognized, the trans- 
verse fracture occurring near the ends of the bone results in displace- 
ment which must be distinguished from a carpometacarpal or a pha- 
langeal dislocation. A fracture, which is not uncommon and is often 
overlooked, is the "chipping" fracture, which most often occurs 
at the base, but may be found at either extremity of the bone. 

Diagnosis.— The diagnosis is made by the history of the injury and 
the location of the wincing tenderness. Indirect tenderness, elicited 
by firm pressure upon the finger in the line of the metacarpal, is of 
value when present, but it may be absent in some cases of gross fracture. 
It is often not well defined in the chipping fractures of the extremities 
of the bones. 

Treatment.— The treatment depends upon the displacement. In 
cases in which the fragments are in good position, a long dorsal splint, 
which puts the hand and fingers at rest and leaves the ends of the 
fingers uncovered, fulfils all requirements. Lateral pressure from the 
use of a tight bandage is especially to be avoided in fracture of the 
second and fifth metacarpals, as it tends to cause lateral displacement. 

It is important, whenever possible, to free the fingers so that slight 
motion is possible after the third day, for marked stiffness is likely to 
follow when the fingers are fixed for a considerable period in the 
extended position. However, in a few cases, the tendency to shortening 
requires fixation of the corresponding finger in the extended position 
for ten days or two weeks. In such cases, traction may be necessary, 
and it can be secured by attaching strips of adhesive plaster to the 
lateral surfaces of the finger involved, and allowing them to project 
beyond the finger tip, forming a loop. If now the splint is put on in 
such a manner that it is firmly attached to the forearm and extends 
an inch or so beyond the finger tip, the loop may be attached in such a 
way as to exert traction upon the metacarpal bone through the finger. 
The attachment of the loop to the splint should be adjustable, so that 
it may be tightened when the occasion demands. A weight (4 to 16 
oz.), hung from the loop and allowed to exert traction in the long axis 
of the injured bone for from one to three hours during the day, acts as 
an additional measure against the shortening; or a rubber band placed 
between the strips and the end of the splint will accomplish the same 
result. 

A very convenient dressing, when the displacement is slight, consists 
in closing the hand and fingers over a roller bandage and holding them 
in that position by adhesive plaster or a bandage. This prevents 
anterior angulation, and preserves the natural curve of the bone which 
makes for the return of strength and function to the injured hand. In 
transverse fracture near the end of the bone (resembling dislocation) 
reduction should be made and the finger put up in extension, with 
pressure exerted by means of a gauze pad on the displaced extremity 
of the metacarpal. 



FRACTURE OF THE PHALANGES 



271 



In the case of the first metacarpal, the direction of action of the 
carpometacarpal joint and its location make the above methods 
inapplicable, and special splints must be designed for the proper 
treatment of fracture of this bone. A plaster-of-Paris bandage includ- 
ing the wrist and thumb, so applied as to hold the metacarpal in 
complete extension, will be found suitable in most cases. If extension 
is necessary, a splint must be made which has a lateral projection in the 
direction of the extended thumb. Adhesive-plaster strips attached to 
the thumb and made fast to the lateral projection of the splint provide 
the necessary extension. 

FRACTURE OF THE PHALANGES. 

As phalangeal fractures are usually the result of direct violence, 
they are likely to be compounded, with consequent liability to suppura- 
tion and stiffening of the fingers. The terminal phalanx is most fre- 
quently involved. 




Fig. 181. — Fracture of the proximal phalanx of the right thumb. 

Diagnosis rests upon local tenderness and crepitus, which are usually 
easily obtained. The roentgen ray of these superficial bones shows 
any bony irregularity with great distinctness. 

The ordinary baseball finger is usually a chipping fracture of the 
end of the phalanx, often with anterior or lateral sliding, thus giving 
shortening of the phalanx and an increase in the diameter of the joint. 
Sometimes, where a fragment is short, it may turn upon itself through 
an angle of 90 degrees. 

Treatment.— The treatment is usually simple. A light ringer splint 
(an ordinary tongue depressor serves the purpose admirably) applied 
to the dorsum of the finger is ordinarily all that is required. These 
fractures as a rule show little or no tendency to displacement. The 
finger should not be splinted for more than ten days or two weeks, the 
tendency to a stiff finger being combated by early motion and massage. 



272 



FRACTURES AND DISLOCATIONS OF HAND AND ARM 



Anterior angulation should be especially guarded against; it results in 
loss of flexion and weakness in the grasp of the affected hand. Where 
the tendency is present, it may be overcome by bandaging a round 
object, such as a roller bandage, in the palm of the hand and holding 
the finger in contact with the bandage by a long strip of adhesive 
plaster, which passes from the posterior aspect of the wrist downward 
over the affected finger and up onto the anterior surface of the forearm. 
This effectively prevents anterior angulation, and the pressure of the 
adhesive plaster also tends to prevent any posterior displacement. If 
under this plan posterior displacement occurs a short pad may be 




Fig. 182. — Baseball fracture of the fifth metacarpal. 

placed over the affected phalanx and held in place by the adhesive 
strip. 

Compound fractures occur frequently, in which event it becomes 
necessary to decide upon the advisability of immediate amputation. 
In general, every part of the thumb should be saved whenever possible. 
A stiff finger, on the contrary, is often an incumbrance in manual labor. 
After a long and difficult course of treatment, which results in an 
ankylosed and deformed finger, the patient may be unable to do his 
ordinary work. Frequently in such a case the man returns to the 
surgeon voluntarily requesting an amputation, Consequently, the 



FRACTURE OF THE PHALANGES 



273 




Fig. 183 




Fig. 184 
Figs. 183 and 184. — Fracture of the first phalanx of the little finger. Roentgeno- 
graph shows why all attempts at closed reduction failed, Also the necessity of taking, 
two views, 

18' 



274 



FRACTURES AND DISLOCATIONS' OF HAND AND ARM 



facts should be carefully weighed, and if the indications point to the 
possibility of bone infection and a resulting deformed finger which 
would probably be a hindrance to the patient, primary amputation 
may be advised. The methods of amputation have already been 
outlined in detail. 

Fracture of the Sesamoid Bones.— The sesamoid bones of the 
thumb mav be fractured, generally bv direct violence. Tenderness 
and crepitus are the ordinary symptoms. In the use of the roentgen 
ray, care must be taken not to mistake a congenital bipartite bone for 
a fracture. Sesamoid bones of the fingers, which occur very rarely, 
may be fractured and they give the same symptoms as those of the 
thumb. 

Treatment.— The treatment consists in rest of the thumb (or fingers) 
for a period of about two weeks. 

DISLOCATIONS OF THE SHOULDER. 

The common dislocations of the shoulder, those varieties in which 
the head of the humerus is displaced anteriorly, are termed, according 
to the location of the displaced bone, subcoracoid or subclavicular. 
Other varieties of shoulder dislocation are very rare. They are called 
subglenoid, subacromial, subspinous, and supraglenoid, the names 
varying according to the location of the head of the humerus after the 
dislocation has occurred. The description which follows refers only 
to the anterior variety. 




Fig. 185. — Subcoracoid dislocation of the right arm. 



Treatment.— Reduction of dislocation of the shoulder may be accom- 
plished by traction directed downward and outward. The patient is 
placed in bed, and counterextension is provided by an assistant, who 
grasps the patient about the chest close to the armpits. The surgeon 



DISLOCATIONS OF THE SHOULDER 



275 



now pulls the arm slowly in a downward direction, at the same time 
gradually abducting it until it is at nearly a right angle. If this posi- 
tion is held for a few minutes, especially if at the same time the arm is 
rotated internally, the head of the bone will often slip back into place. 
Several methods have been recommended from time to time which 
are really only modifications of the above. Counter extension may be 
secured by a band fastened about the chest, by the stockinged foot 
placed against the chest (not in the axilla), or by the weight of the 
patient. While traction is being made by an assistant, the surgeon 
may apply pressure to the head of the bone to force it into the cavity 
of the joint. Stimson's treatment consists in placing the patient on 




Fig. 186. — Kocher's method of reduction of dislocation of shoulder: first position 

(Brewer.) 



his side upon a stretcher which has an opening at the location of the 
shoulder; through this hole the injured arm is passed, and traction 
applied to the injured arm by means of a weight (10 lbs.). This, he 
says, usually results in reduction in a few minutes, and is associated with 
little pain. 

The Kocher method depends upon manipulation to make the head 
of the humerus retrace the path of dislocation and enter the glenoid 
fossa. The movements of reduction are as follows : The injured arm 
is placed against the side, and the forearm flexed to a right angle. The 
forearm is moved outward, the elbow remaining against the side, until 
the forearm is directed laterally away from the body (external rotation 



276 FRACTURES AND DISLOCATIONS OF HAND AND ARM 




Fig. 187. — Kocher's method: second position. (Brewer.) 




Fig. 188.— Kocher's method: third position. (Brewer.) 



DISLOCATION OF THE ELBOW 277 

of the humerus) . Then, while still maintaining external rotation, the 
humerus is moved forward until it is nearly perpendicular to a plane 
passed through the body from side to side. The motion is then 
completed by rotating the arm internally, thus bringing the injured 
hand to the opposite shoulder. Traction in the long axis of the humerus 
is sometimes an aid to reduction. All the motions should be made 
slowly and with a steady force, never quickly or with irregularly 
applied pressure. 

In muscular subjects and for the relief of pain in sensitive patients, 
an anesthetic is often advisable. Nitrous oxide will relieve the pain, 
but ether may be required for proper relaxation in strong subjects with 
well-developed muscles. 

The "heel in the axilla" method and the method by hyperabduction 
should never be attempted, they are both dangerous because of the 
possibility of injury to the nerves and vessels. In this joint especially, 
no method of reduction should be undertaken, until after due con- 
sideration has been given to the danger of nerve or vessel injury. 

After reduction, the arm should be bound to the side for twenty-four 
to forty-eight hours and carried in a sling for a week or ten days longer. 
Massage will give relief from any pain that persists. The patient 
should be warned against too active movements of the joint for from 
six to eight weeks, as this form of dislocation is especially likely to recur. 

Old dislocations of the shoulder have been reduced up to two or three 
weeks or possibly slightly longer. In such cases there is danger of 
fracture, if too great force is applied. Therefore, if an old dislocation 
cannot be replaced by moderately forceful manipulation, the attempt 
should be abandoned and open operation resorted to. 

DISLOCATION OF THE ELBOW. 

Almost any form of dislocation may occur at this point. The radius 
and ulna may be displaced backward or forward or to either side; or 
either bone may be dislocated alone. 

The commonest form is posterior dislocation of both bones, either 
with or without associated fracture of the coronoid process. The 
diagnosis is usually simple, the separation being marked and indicating 
the type of dislocation present. 

It is necessary to differentiate all types of dislocation from fractures 
of the lower end of the humerus with displacement. Limitation of 
motion and the absence of crepitus usually point to dislocation. It 
must be remembered, however, that the two conditions are frequently 
associated. The roentgen ray is of great value in injuries in this region, 
except in children where the cartilaginous ends of the bone are hardly 
dense enough to throw a shadow. 

Treatment.— Where one bone alone is displaced, the articulation of 
the other bone may be used as a fulcrum. In dislocations of both 
bones it should be remembered that the strong biceps tendon forms a 



278 FRACTURES AND DISLOCATIONS OF HAND AND ARM 




Fig. 189. — Posterior dislocation of the radius and ulna, lateral view. 




Fig. 190. — Posterior dislocation of the radius and ulna; posterior view. 



DISLOCATION OF THE ELBOW 279 

protecting band anteriorly, and the triceps tendon a similar band 
posteriorly. Most dislocations may be reduced, if these attachments 
are kept in mind and the two muscles put upon the stretch with the 
forearm at right angles to the arm. 

The chief obstacles to be kept in mind are the tip of the coronoid 
process which is likely to engage firmly in the olecranon fossa in 
posterior dislocation, and the olecranon which, in lateral displace- 
ments, is likely to act as a hindrance to reduction. Reduction of 
posterior dislocation may be secured by means of flexion and counter- 
pressure. It is accomplished as follows: The patient is seated, the 
injured arm hanging by the side, the forearm being flexed nearly to a 
right angle. The surgeon grasps the wrist with one hand, and holding 
it as a fixed fulcrum in a semi-flexed position, presses downward with 
the other hand upon the forearm, near the flexure of the elbow. When 
the slow, steady pressure has overcome the contraction of the muscles, 
the coronoid will slip under the trochlear surface of the humerus, and 
the reduction can be completed by flexion of the elbow. 

The same result may be accomplished by traction combined with 
hyperextension. The arm is firmly held by an assistant, and the 
forearm is hyperextended, the tip of the ulna acting as a fulcrum as it 
rests against the posterior surface of the humerus. When hyper- 
extension is sufficient to disengage the tip of the coronoid process from 
the olecranon fossa (about 20 degrees), traction is made in the long 
axis of the arm, and reduction is completed by the flexion of the forearm. 

For lateral and other dislocations of the elbow, traction and direct 
manipulation of the ends of the bones will usually accomplish reduction. 

Fracture of the coronoid, complicating dislocation of the elbow, 
requires no special treatment. Fractures of the olecranon, when they 
occur, or other fractures about the joint, should receive the appropriate 
treatment of the lesion present. 

The after-treatment of dislocated elbow consists in fixation, with the 
joint at a right angle for about a week, except where there is fracture 
of the coronoid process, in which case the joint should be supported 
for two or three weeks. A posterior plaster splint, which is light and 
easily removed, extending from the upper part of the arm to the wrist, 
is the best means of fixation. After the swelling has begun to subside, 
massage may be begun, but extensive motion had better be deferred 
until the ligaments have had a chance to heal firmly. In any event, 
while passive motions are desirable after the first few days, they 
should never be persisted in when they cause severe pain. After 
several weeks have elapsed, stronger movements may be initiated, and 
mechano- therapy may be resorted to. 

Old dislocations of the elbow may sometimes be reduced after a 
month, and reduction may even be attempted up to six or seven weeks. 
Should reduction fail, operation is indicated. 



280 FRACTURES AND DISLOCATIONS OF HAND AND ARM 



SUBLUXATION OF THE HEAD OF THE RADIUS. 

In subluxation, dislocation downward of the head of the radius 
carries it partially through the orbicular ligament. It occurs in 
children, and is usually caused by pulling upon the extended forearm, 
as in lifting a child by one arm. The child cries with pain and holds 
the forearm partially flexed and slightly pronated. Motions of the 
joint are resisted on account of pain. 

Treatment.— Reduction is usually easy, being accomplished by 
forcible extension of the forearm, which causes the head of the radius 
to slip back into place. If this is not successful, the surgeon grasps 
the hand on the injured side, and holding the arm steady, presses the 
radius toward the elbow, at the same time pronating and supinating 
the hand. This works the head back through the loop of the orbicular 
ligaments. Operative interference is rarely required. 

DISLOCATION OF THE WRIST. 

For all practical purposes the diagnosis of dislocation of the wrist- 
joint should never be made. While cases have been reported, they are 
so rare as to be surgical curiosities. Almost every case which is 
diagnosed as dislocation of the wrist proves upon roentgen-ray examina- 
tion to be fracture of the lower extremity of the radius. 

Dislocation of the carpal extremity of the ulna alone, although rare, 
is occasionally seen. It may be anterior, posterior, or internal. 
Reduction is usually made by direct pressure and abduction at the 
wrist. It is necessary to see that the tendon of the extensor carpi 
ulnaris is in place after reduction, because it may, if displaced, cause 
a recurrence of the deformity. 

DISLOCATION OF THE CARPAL BONES. 

Dislocation of the midcarpal joint has been reported. Pure dis- 
location is rare but fracture-dislocation is not infrequent. The distal 
portion of the carpus is displaced backward, the scaphoid, and occasion- 
ally the tip of the radius, being the bones ordinarily broken. 

Treatment.— Reduction is effected by hyperextension, with traction 
and pressure upon the anterior aspect of the wrist, followed by flexion 
with fixation in the flexed position. If reduction is impossible, as in 
old untreated cases, removal of the semilunar bone and the displaced 
fragment of the scaphoid is indicated. 

Dislocation of the Semilunar.— Dislocation of the semilunar either 
alone or in combination with a fracture of one of the other carpal 
bones, is a fairly frequent injury. In a tabulation of the various 
injuries to the carpus, fracture of the scaphoid was most frequent 
and dislocation of the semilunar ranked next. The bone is usually 
displaced anteriorly, rotating upon itself through a transverse axis. 



DISLOCATION OF THE METACARPAL BONES 281 

Treatment.— Reduction, which is difficult, is accomplished by means 
of hyperextension of the wrist, which permits the bone to be pushed 
into place, followed by flexion and fixation in the flexed position. If 
reduction is not accomplished, early or later removal of the bone will 
be followed by good functional results. 

The other carpal bones may be dislocated. Such an injury, though 
rare, may be suspected when the small bone is felt as a hard projection 
beneath the skin. No special treatment has been worked out for most 
of these cases, so that the surgeon is dependent upon the general 
indications. In compound dislocations showing a dislocated carpal 
bone in the wound, immediate removal of the displaced bone gives 
better results than conservative treatment. 

In thin persons of poor muscular development, dislocation of the 
carpal bones posteriorly may occur as a result of some unusual motion 
of the hand. In a woman patient under our observation, a posterior 
dislocation occurred at intervals of six months or a year. When the 
dislocation occurred the patient would experience severe pain and would 
drop whatever she was carrying. There was a bony prominence 
posteriorly, which could be forced back into place with relief of pain, 
but which tended to slip out again unless held in place for a week or 
ten days with adhesive strips. 

DISLOCATION OF THE METACARPAL BONES. 

Any one or more of the metacarpal bones may be dislocated at the 
carpometacarpal joint, either forward or backward. Dislocation of the 
first metacarpal bone (thumb) is common, while dislocation of the 
other bones is extremely rare. 

Dislocation of the Thumb.— Dislocation of the thumb at the carpo- 
metacarpal joint must be differentiated from the more common injury, 
transverse fracture of the base of the metacarpal bone. Crepitus and 
shortening, which indicate fracture, are absent in dislocation. The 
diagnosis may be confirmed by the roentgenograph. 

The dislocation is usually backward, and may be complete or incom- 
plete. The projection of the metacarpal bone is felt between the 
extensor tendons, and the trapezium is felt as a distinct lump in the 
ball of the thumb. Reduction is accomplished by traction upon the 
thumb with pressure directed downward against the projecting end of 
the bone. Once reduced, extension of the thumb has a tendency to 
hold the bone in place, but as the displacement easily recurs, the 
extension must be maintained for two or three weeks with either a 
plaster bandage or other suitable splint. For the same reason, early 
passive motion is contraindicated. 

In some cases the deformity recurs in spite of extension. These 
should be operated upon, the attempt being made to repair the capsule. 

In dislocation of the remaining metacarpals, reduction has usually 



282 FRACTURES AND DISLOCATIONS OF HAND AND ARM 

been obtained in the same manner as in the thumb. In most of the 
reported cases, the displacement is likely to recur in spite of attempts 
to maintain reduction. This injury, however, occurs so rarely that 
there is no widely recognized plan of treatment. 

DISLOCATION OF THE PHALANGES. 

Dislocation of the Thumb.— The proximal phalanx of the thumb 
is more frequently dislocated than any of the other phalanges. The 
usual form is backward or posterior dislocation, in which the base of the 
phalanx rests upon the posterior surface of the metacarpal. 

Incomplete dislocation, which is frequently seen, especially in the 
young, is caused by an abnormal laxity of the anterior ligaments which 
permits the articular surface of the phalanx to rest against the posterior 
surface of the head of the metacarpal. In this position the tendons of 
the small muscles of the thumb are posterior to the normal center of 
motion and tend to hold the bone in a position of subluxation. Many 
people can voluntarily produce this dislocation, which is easily reduced 
and has no. special significance. 

Complete dislocation posteriorly is permitted through the tearing 
of the strong anterior ligament of the joint. The phalanx rests upon 
the posterior surface of the metacarpal bone either perpendicular to, or 
in a line parallel to, the long diameter of the metacarpal. 

The head of the metacarpal passes through the rent in the capsule, 
leaving the tendons of the short muscles of the thumb with the accom- 
panying sesamoid bones on either side, and the long flexor tendon 
either anteriorly or to the inner side. The above description of the 
pathology is important for a clear understanding of the difficulties of 
reduction. 

There are three elements in this dislocation which may prevent 
reduction. They are: The tendon of the long flexor of the thumb, 
which may become engaged behind the inner (very rarely the outer) 
side of the head of the metacarpal; the short tendons of the muscles 
of the thumb, with the attached sesamoid bones, which are made tense 
and consequently grasp the neck of the head of the metacarpal firmly; 
and the capsule itself, which, after allowing the head of the bone to 
pass the opening, acts like a buttonhole and prevents the return of the 
head into the joint-cavity. 

Treatment.— The tension of the short muscles are relaxed by flexion 
of the first metacarpal bone (that is, it is moved over toward the center 
of the palm) . The perpendicular position of the phalanx being main- 
tained, it is drawn downward until the head of the metacarpal bone 
slips through the "buttonhole" opening in the capsule. Flexion of the 
phalanx then completes the reduction. Fixation for about two weeks 
is usually sufficient. 

In cases in which the above method does not succeed, pressure back- 
ward upon the head of the metacarpal may be combined with the 



DISLOCATION OF THE PHALANGES 



283 



above described manipulation. Occasionally this fails, but if we 
remember the buttonhole character of the opening and that the long 
tendon is usually located internally, we can sometimes manipulate the 
thumb in such a manner as to slip the tendon with the capsule attached 
over the head of the bone, reduction then being comparatively easy. 
Traction in the long axis may be tried, but this is rarely successful when 
other methods have failed. Dislocation of the thumb is one of the 
hardest dislocations to reduce. In two cases treated by us, it was 
necessary to use a sharp hook passed through the skin and below the 
bone in order to get enough traction. 

It is far better to resort to open operation than to cause extensive 
laceration of the parts from continued traction and manipulation. 
An incision made in the midline of the thumb over the metacarpal 
bone reveals the head of the bone presenting through the rent in the 
capsule, and the rent firmly grasping the neck of the bone, thus prevent- 
ing reduction. If the torn edge is nicked slightly at the upper part, 
the bone slips easily into place. The skin wound is closed without 
any attempt to suture the torn capsule, and the thumb is fixed in a 
plaster bandage for two weeks. 




Fig. 191. — Lateral dislocation of middle on proximal phalanx. (Ashhurst.) 

In old cases the head of the bone may be excised, but even where 
there is considerable deformity, amputation should not be permitted 
because a thumb, even though showing marked deformity, will prove 
of much more value than a metacarpal stump. Forward dislocation, 
though rare, is usually easily corrected by traction and fixation in the 
partially flexed position. 

Dislocation of the terminal phalanx may occur either forward or 
backward. The bone may be hyperextended, or straight, or flexed 
across the end of the proximal phalanx. The tendon, or the long 
flexor, or the buttonholing of the capsule may prevent reduction. 
Traction and pressure upon the displaced bone are the indicated methods 
of treatment. If this is impossible, the joint should be exposed, and 
the tendon or ligament divided. 

Dislocation of the Fingers.— Although dislocation of any of the 
phalanges may occur, the proximal phalanges are seldom dislocated, 
owing to their strong ligamentous attachments. When such injury 



284 



FRACTURES AND DISLOCATIONS OF HAND AND ARM 



does occur the head of the metacarpal is felt as a hard, painful lump 
in the palm. Because of the swelling, the deformity on the dorsum of 
the hand is not evident. A ten-year-old girl recently presented 
herself with a painful lump in the palm of the hand which was tense, 
red and tender. As the child remembered no injury, the redness and 
pain seemed to indicate infection, and an incision was made. The 
hard lump proved to be the dislocated head of the second metacarpal 
bone. 

The second and third phalanges are usually dislocated posteriorly 
or laterally. Anterior dislocations are extremely rare, and are often 




Fig. 192. — Posterior dislocation of the little finger. 



accompanied by fracture of a fragment from the rim of the articular 
surface. 

In incomplete dislocation at the metacarpophalangeal joint, reduc- 
tion may be made by traction and direct pressure; but in the complete 
variety, the obstruction is of the same character as in the case of the 
thumb, and the same method of attack is applicable. After reduction, 
the fingers are usually put up in the position of flexion. Dislocation 
of this joint anteriorly can be overcome by traction and coaptative 
pressure. 

In dislocation of the second and third phalanges, the relation of the 



DISLOCATION OF THE PHALANGES 285 

tendon should always be borne in mind. Reduction by manipulation 
is usually easy, but occasionally interposition of the tendon or ligament 
makes reduction impossible. Where reduction is not complete, the 
finger should be incised, the capsule exposed, and the impediment to 
reduction severed or removed. In unreduced dislocations, if the bone 
does not easily slip into place, it may be pried into place with a peri- 
osteal elevator, after first excising all the scar-tissue which may be filling 
the cavity of the joint. The incision is made, as a rule, along a lateral 
margin of the anterior surface of the finger, and the joint is exposed. 
As in any operation upon a bone or joint, especial care should be taken 
not to introduce infection into the joint, and to this end the finger 
should never enter the wound, and catgut sutures or other foreign 
bodies should not be left to cause irritation. For this reason, suture 
of the capsule is not advisable. 

In old dislocations it is often necessary to remove considerable scar- 
tissue and to divide several ligaments before the bone can be replaced. 
Practically all old dislocations require open operation for reduction. 
After the bone is reduced, the skin wound should be closed without 
drainage. 

In old dislocations, especially in children, new joints are likely to be 
formed and functional use of the finger may be possible to a considerable 
degree. It is usually advisable not to interfere with cases showing 
fair function if the dislocation has lasted a long time, for permanent 
stiffness may follow and the result be less satisfactory then before the 
operation. 



CHAPTER IX. 
INJURIES OF THE ARM AND HAND. 

CONTUSIONS OF THE ARM AND HAND. 

Contusions of the arm and hand are of frequent occurrence. In 
the region of the axilla they may be associated with injury to the large 
vessels or to the brachial plexus. In the forearm and about the elbow 
careful examination should be made in order to exclude fracture. 
Occasionally following the laceration of one of the larger vessels, or of 
a muscular branch, a large dissecting hematoma may occur. This 
condition either follows along the deep lines of cleavage or along the 
fascia. In doubtful cases the roentgen-ray examination should not be 




Fig. 193. — Large diffused hematoma of the arm from a blow. 

omitted. A contusion over a joint may be associated with bleeding 
into the joint and subsequent signs of hemarthrosis. No special 
treatment is required for uncomplicated contusions in this region. 

WOUNDS OF THE ARM AND HAND. 

In wounds occurring about the arm and hand the chief interest lies 
in the nature of possible injury to the underlying parts. Because of 
the large number of nerves and tendons located somewhat superficially, 
and because a good functional result is essential for the finer move- 
ments of the fingers and hand, the early treatment of deep wounds in 
this region is of extreme importance. 



WOUNDS OF THE ARM AND HAND 



287 



Every wound should be carefully inspected when first seen by the 
surgeon. The muscular and nerve function must be tested in order to 
determine the extent of injury to the underlying structures. As the 
help of the patient is required, the examination should not be made 
under anesthesia. Even small puncture wounds may completely 
sever an important tendon or nerve. 

If the wound is seen early, before there are evidences of infection, 
it should be thoroughly cleansed and the divided tissues carefully 
repaired. If the wound is large it is better to give an anesthetic for 
this purpose and if necessary to enlarge the opening so as to secure 
complete exposure of retracted tendons or nerves. The operation 
should be performed with aseptic technic and with every attention to 
detail, for on its success depends the functional use of the arm and hand, 




Fig. 194. — Atrophy of the shoulder and arm from a stab wound in the neck. Duration, 
seven months. Hand and forearm normal. 



which from an economic standpoint is much more important than 
functional use of the lower extremities. In the after-treatment the 
surgeon must base his judgment upon a knowledge of what has already 
been said regarding wounds. If it is reasonably certain that the wound 
is clean, it is much better to close it by primary suture, as healing by 
granulation is certain to result in many adhesions and loss of function. 
Even in wounds almost certain to be infected, the tendons and nerves 
should be sutured and the wound partially closed. If infection occurs, 
it is a simple procedure to open the wound and allow free drainage. 
If, on the other hand, the wound heals primarily, the maximum func- 
tional gain has been obtained. 1 

1 We have seen tendons and nerves join and functionate after primary suture in spite 
of extensive and severe infection. It is probable that in these cases a partial union has 
taken place before suppuration occurs, in other words that the infection remains to a 
certain extent localized if the drainage is free. 



288 



INJURIES OF THE ARM AND HAND 



If the wound is suppurating when first seen, no attempt should be 
made to place sutures in the infected tissues. Antiseptic treatment 
should be started at once and continued until the wound is sterile. 
Secondary closure may then be performed, but if there is extensive 
repair of nerve or tendon tissue, it should not be attempted until the 
wound is completely healed. When this has occurred and there is no 
evidence of infection, the operative repair of the divided structure 
may be performed under aseptic conditions. 

Blank-cartridge Wounds.— Blank-cartridge wounds of the hand 
differ from ordinary gunshot wounds, because as a general rule the 
hand is held so close to the muzzle of the gun, that the gas follows the 
wad and loosens a large area of skin on the opposite side of the hand. 

The commonest site for these wounds is the palm, where the point 
of entry is small and usually surrounded by an area of powder burn. 
Where the point of entry is in the palm, a track, the size of the wad, 




Fig. 195. — Gridiron method of marking with silver nitrate to locate in the roentgen 
ray, a foreign body in the palm. (After Brown.) 

usually passes between the metacarpal bones ; and on the dorsum of the 
hand, an area of skin, one or more inches in diameter, is loosened from 
the underlying tissues. This loosened area contains the wad and 
powder grains. In these cases, the point of entry so much resembles 
a superficial wound, and so little disturbance is noted on the dorsum 
of the hand, that often the doctor who originally treats the wound does 
not suspect the deeper lesion. Hence, a great many of these cases 
present themselves a few days later with a suppurative process that 
requires a dorsal incision for the removal of the wad ] and powder. 

Treatment.— In all blank-cartridge wounds, the wound should be 
probed and the wad searched for. If the track passes between the 
metacarpal bones to the dorsum of the hand, a dorsal incision, suffi- 
ciently extensive to expose the whole cavity, should be made. After 
all the powder and the wad have been removed, a syringeful of iodine 
should be injected through the sinus from the palm to the dorsum, so 
that the whole tract is sterilized. A small drain should be inserted 

i Blank cartridges usually contain more than one wad, 



NERVE INJURIES 



289 



in the dorsal wound, and the wound dressed in the usual manner. 
Tetanus antitoxin should always be given. A roentgen ray should be 
taken in all cases. 

NERVE INJURIES. 

Rupture of the brachial plexus may occur either with or without 
injury to the other tissues. The accident occurs when the patient's 
arm has been forcibly pulled in a direction away from the body. Bris- 
tow has reported a case, due to the arm becoming entangled in a rope 
pulled by a steam winch, in which there was almost complete paralysis 
of the nerves of the arm. A similar condition may result from blows 
on the side of the neck. The area of paralysis varies with the extent 
of the trauma. There may be extreme pain along the nerves involved, 
possibly due to an accompanying neuritis. The same force which 
caused the injury may cause dislocation or fracture of the shoulder. 
The arm usually hangs limp at the side in a position of internal rotation. 
This injury occurring in the new-born is called birth palsy. 




Fig. 196. — Wrist-drop resulting from musculospiral injury during operation. 

In mild cases where the nerves are merely stretched, regeneration 
will occur if the arm is fixed for about two weeks in a bandage which 
elevates the shoulder. In severe cases the nerves must be repaired by 
operation. 

The musculospiral nerve is frequently injured near the middle of the 
humerus. It may be divided by wounds or ruptured when the bone 
is broken. Fairly often, following fracture of the middle third of 
the humerus, the nerve becomes caught in the callus formation, which 
may cause partial or complete paralysis below the point of pressure. 
Division or injury of the musculospiral nerve causes an extensor palsy 
with wrist-drop. The finger may be extended at the interphalangeal 
joints by the lumbricales and interossei, but the posterior extensors 
are completely paralyzed. Suppination is generally completely lost, 
while there is only slight loss of sensation in the hand. 

The median nerve may be injured high above the branches to the 
long flexors. In complete paralysis, pronation of the forearm is 
19 



290 INJURIES OF THE ARM AND HAND 

impossible, and flexion of the fingers is almost entirely lost. The 
thumb is held extended, flexion and abduction is impossible, and it 
cannot be approximated to the fingers. Sensation may be completely 
lost over the area of cutaneous distribution of the nerve. Occasionally 
the loss of sensation is less extensive, and in rare cases there may be 
little or no change in cutaneous sensation, owing to the communication 
from surrounding nerves. 

The most frequent injury to the median nerve is traumatic division 
in the region of the wrist. Here the nerve lies very close to the surface 
and may be lacerated or incised by comparatively superficial wounds. 
The long flexors are, of course, not interfered with, but there is paralysis 
of the small muscles of the thumb, with loss of sensation over the palmar 
aspect of the thumb, index, and middle fingers. 

The ulnar nerve is apt to be divided high up. This results in paralysis 
of the flexor carpi ulnaris and almost complete paralysis of the interossei 
and lumbricales. The loss of the use of the small muscles of the hand 
causes loss of flexion of the fingers at the metacarpophalangeal joint, 
and loss of extension at the interphalangeal joints. Sensation is lost 
over the ulnar distribution in the hand generally, including the little 
and ring fingers, and the corresponding portion of the palmar and 
dorsal aspects of the hand. When the nerve is wounded in the wrist, 
the paralysis of the small muscles is as outlined above, but the sensory 
paralysis is less clearly defined. In either high or low wounds of the 
ulnar the paralysis of the interossei causes the hand to be held in a 
position which is commonly called claw-hand, the first phalanx being 
overextended and the others being flexed. 

Treatment.— Treatment of divided nerves, as has been outlined in 
another chapter, consists in early suture. Always suspect a nerve- 
injury in wounds in the region of the wrist, and test carefully for its 
presence. The nerve should be sutured before twenty-four hours, 
if possible, but suture is fairly easy at any time within two weeks. 
The return of sensation may be rapid, occurring within a few days, 
or it may require six months or longer. If a considerable time has 
elapsed, there will be retraction of the cut ends, suture will be difficult, 
and some form of bridge will be required. 

In the repair of nerves, the suture should be passed through the 
sheath and tied in such a manner as to bring the cut ends of the nerve 
together. The sutures must not pass through the nerve, but must 
include only the perineurium and connective tissue. 1 After the nerve 
is sutured the line of sutures should be surrounded with fascia to 
prevent adhesions. After the deep tissues are repaired, the skin must 
be carefully sutured and the arm placed on a splint in a position which 

1 It is only fair to say that in many cases this is most difficult and the unsuccessful 
attempts to suture the nerve without passing the needle through the substance of the 
nerve itself cause severe injury. In many cases we pass a single suture directly through 
the nerve as a stay suture and then use small suture for accurate coaptation of the cut 
ends. 



MUSCLE INJURIES 291 

relaxes the nerve. Until function is restored, the hand or arm should 
be supported to prevent contraction of the opposing group of muscles. 
Treatment by massage, passive motion, and electricity should be kept 
up until function returns. As soon as voluntary motion returns, the 
muscle should be exercised at intervals, with the splint removed. 
When voluntary motion is complete the splint may be dispensed with, 
but exercise must be continued until the muscular atrophy has entirely 
disappeared. 

Secondary suture is less satisfactory than primary suture, for it is 
usually much more difficult to perform and less apt to be followed by 
complete return of function. Careful attention to technic is required, 
for rough handling of the nerve may prevent regeneration. The scar 
must be dissected away and all scar-tissue cut from the end of the nerve. 
If the ends cannot be brought together, it is necessary to bridge the 
interval with a flap from one or both ends of the injured nerve. 

Dislocation of the ulnar nerve is a rare condition which may be 
associated with fracture or dislocation at the elbow or may occur with- 
out other complications. It is usually associated with pain and some- 
times with anesthesia in the region of ulnar distribution. The treat- 
ment consists in operative exposure and replacement of the nerve. 
If secondary to fracture, it may be necessary to excise the fibrous 
tissue which has accumulated in the ulnar groove. The nerve is held 
in place by sutures passed through the fascial expansion of the triceps 
tendon or by a bridge of fascia. 

Contusion of the ulnar nerve may result from a~blow on the elbow. 
There may be complete paralysis, which usually disappears in a few 
weeks. The treatment consists in rest followed by massage, baking, 
and electricity. 

MUSCLE INJURIES. 

Wounds of Muscles.— Wounds of muscles are frequent complica- 
tions of incised and lacerated wounds of the arm and forearm. If 
the wound is very small in the body of the muscle, it may be disre- 
garded ; but if it is extensive or if, though comparatively small, it causes 
complete division of a muscle, the muscular tissue should be sutured. 
If there is no tension, plain gut may be used, but if there is much tension 
No. 1 chromic gut is preferable. The sutures should be tied only just 
tight enough to approximate the muscle. If tied too tightly they are 
likely to cause constriction and to cut through. After the wound is 
closed, the arm should be placed in a splint to relax the affected muscle 
or muscles. Early motion and massage are required to prevent 
adhesions. 

Muscle Strain.— Muscle strain is of common occurrence in the arm. 
The ordinary " lawn-tennis arm" is a strain of the pronator radii teres, 
and "baseball arm" is a strain of the biceps. Strain is caused by a 
stretching of the muscle in its long axis, with the tearing of a few fibers. 



292 



INJURIES OF THE ARM AND HAND 



There are exudation into the muscle-sheath and extreme pain when 
the muscle is put on the stretch. The arm is swollen, stiff and tender. 1 

Treatment.— Treatment consists in rest during the early stages with 
support secured by bandages or adhesive straps for a few days, followed 
by active motion and massage. Fixation for long periods is not 
advisable, because it is likely to be followed by adhesions and chronic 
stiffness of the arm. 

Rupture of the Biceps Muscle.— This injury is not uncommon. It 
results from muscular action and is more frequent in men than in 
women. The ordinary history is that the patient, while lifting a heavy 
object, suddenly experienced a sharp pain in the arm. The rupture 
may occur in any part of the muscle-belly or at the insertion of the 




Fig. 197. — Hernia of the right biceps through a ruptured muscle sheath in circus strong 

man, aged sixty-eight years. 

tendon. The gap in the muscle may be felt with the examining finger; 
and when the elbow is actively flexed, a muscular lump appears, usually 
nearer the elbow than normally, but it may be nearer the shoulder. 
If the rupture is near the center of the muscle-belly, two lumps may be 
seen with a distinct gap between. Fairly frequently the long head is 
forcibly torn from the insertion to the bone. After the accident the 
arm is swollen and painful. Flexion of the elbow is possible, but much 
weaker than under normal conditions. Flexion with the forearm 



1 Muscle strain, with more or less injury to the muscle due to the tearing of the fibers, 
is a more common injury than is ordinarily thought. It frequently is undiagnosed. 
Sneezing may cause a tearing of an intercostal muscle which is liable to be diagnosed as 
fracture of the rib or intercostal neuralgia. Muscles which are commonly torn and are a 
frequent cause of persistent pain are the latissimus dorsi, the teres major, the coraco- 
brachialis and the supraspinatus. Strain of the last named is frequently mistaken for 
subdeltoid bursitis. 



MUSCLE INJURIES 293 

pronated is stronger than when the movement is attempted with the 
forearm in supination. 

A hernia of the biceps occasionally occurs and resembles rupture. It 
is usually secondary to wounds which involve the muscle-sheath. A 
portion of the muscle protrudes through a wound in the sheath when the 
muscle is contracted, forming an irregular lump. 

Treatment.— If the rupture is limited in extent and there is no great 
separation of the torn ends, the injury may be treated as a severe strain. 
It is well to place the arm at rest for several days, and to follow this 
treatment by massage and the application of heat. Prolonged rest is 
not advisable as it may lead to adhesions. Adhesive-plaster strapping 
forms an efficient support for the muscle during the period of recovery, 
giving support and at the same time allowing a certain amount of 
motion. When there is a definite separation of the torn ends, the 
ruptured muscle should be exposed by incision and the ends sutured 
with chromic gut. Hernia of a portion of the biceps through an open- 
ing in its sheath is treated by incision and suture of the sheath. 

Rupture of the Triceps Tendon.— Rupture of the triceps tendon is 
caused by muscular action in the same manner as fracture of the 
olecranon, which it resembles and from which it must be differentiated. 
Careful examination shows a groove above the tip of the ulna without 
bony deformity. Active extension of the elbow against gravity is 
impossible. There may be an effusion into the elbow joint but this is 
rather uncommon. The treatment consists in operation and suture as 
in fracture of the olecranon. Non-operative treatment consists in the 
use of a splint which holds the elbow in extension in the endeavor to 
approximate the ruptured ends of the tendon. The results of this 
method of treatment are unsatisfactory if there is more than a very 
slight separation. In practically every case operation should be 
advised. 

Rupture of the Long Extensor of the Thumb.— The long extensor 
of the thumb may be ruptured by muscular action. This is usually 
associated with an injury to the wrist or thumb. Operation, with 
suture of the torn tendon, should be performed before contraction of 
the muscle causes retraction of the tendon, preferably within the first 
three days. 

Wounds of Tendons.— Important tendons may be divided by com- 
paratively insignificant wounds. Every wound about the hand or 
wrist, no matter how slight, should give rise to the suspicion of tendon 
injury. The diagnosis is made on loss of function of the divided tendon. 
Care should be taken not to ascribe the loss of flexion or extension of a 
finger to pain, when it is really due to division of a tendon. In clean 
wounds, the patient will be able to move all intact tendons with little 
or no pain. In testing the movements, the muscle should be made to 
act against gravity. If the division of the extensors of the fingers is 
suspected, the hand should be tested while held palm downward; if 
the flexors are suspected, the position should be reversed. About the 



294 INJURIES OF THE ARM AND HAND 

wrist and fingers, the wound itself should be carefully inspected for the 
cut ends of tendons. In clean wounds, and in all recent wounds, never 
neglect to suture all divided tendons as soon as possible. In infected 
wounds it is better to wait for healing before attempting suture. 

Dislocations of Tendons. — The dislocation of the long head of the 
biceps is of not uncommon occurrence. The condition may follow 
injury or be due to a chronic arthritis. The muscle is still able to 
functionate but less efficiently than under normal conditions. Disloca- 
tions of the flexor carpi ulnaris, the extensors longus and brevis pollicis, 
and the extensor tendons of the fingers may occur. The diagnosis of 
dislocation is made by direct examination. When the muscle contracts, 
the tendon may be felt to slip from its groove, or the groove may be 
empty, the tendon being permanently displaced. Conservative treat- 
ment is usually satisfactory; unless the condition gives rise to discom- 
fort. When there is pain or loss of function, an incision should be made 
and the tendon replaced in its groove. Several sutures should be 
taken in the sheath to prevent recurrence. When the long head of the 
biceps has been replaced by operation, the shoulder and elbow should 
be fixed in a Velpeau bandage for about a week. Gentle movements 
are made after the third day to prevent adhesions. 

Traumatic Tenosynovitis.— Traumatic tenosynovitis is common in 
the extensor tendons of the wrist. It may be caused by a blow, but is 
most frequently caused by unusual muscular exertion in persons 
unaccustomed to hard work. In winter it is frequently seen in snow- 
shovelers and in teamsters, being almost always associated with a 
history of muscular exertion combined with exposure to cold. In 
summer it is seen in tennis players and after rowing. The patient 
complains of pain and weakness in the hand and forearm. Often the 
complaint is "sprained wrist." Examination shows swelling along 
the dorsum of the wrist and forearm and a distinct leathery crepitus 
when the tendons are moved. Any other tendon sheath may be 
involved in the same manner, but clinically, except for the cases 
involving the flexors and extensors of the fingers and toes, the condition 
is not commonly recognized as such. It seems to be more common in 
those sheaths which are partially attached to the bone. We have seen 
several cases of tenosynovitis of the sheath about the long head of the 
biceps and of the sheaths about the tendons which evert the foot. One 
particularly interesting case occurred in the sheath of the popliteus 
tendon. This recurred several times, and was finally cured when the 
sheath was dissected out. 

Treatment. —The treatment consists of adhesive strapping to support 
the region involved and the use of heat for the relief of pain. Moderate 
function of the part is permitted. When the extensors of the fingers 
are involved, the strapping should be applied from the metacarpo- 
phalangeal joint to the mid-forearm and allowed to remain in place for 
about a week, after which time it is removed to permit the cleansing 
of the skin with alcohol or ether. The strapping is immediately 



CRUSHING INJURIES OF THE FINGERS 295 

reapplied in the same manner, and again renewed about the beginning 
of the third week. A bandage over the adhesive straps gives additional 
support. Cure is usually obtained in about three weeks, but recurrence 
is common. In some persistent cases, operation with dissection of the 
tendon sheath may be required. 

Mallet-finger.— This is due to the tearing of the extensor tendon 
from the last phalanx of the finger. The primary injury is usually 
slight and does not ordinarily come under the care of the surgeon. In 
untreated cases the first complaint is the inability to extend the terminal 
phalanx. If it occurs in the index finger it may cause great inconven- 
ience; occurring in any of the other fingers the inconvenience is much 
less. If it has existed for a year or longer, contraction in the flexors 
and bone changes may cause fixation of the phalanx in a position of 
permanent flexion. This is termed "mallet-finger" or " hammer- 
finger." 

Treatment.— If seen in the early stages immediately after the acci- 
dent, the fingers and hand should be splinted in the position of extreme 
flexion for about two weeks. This will occasionally result in a cure. 
When this form of treatment is unsuccessful and in untreated cases, 
incision and suture of the tendon are required. A Y-shaped incision 
is made just above the nail, with the perpendicular bar of the Y 
extending up the midline of the dorsum of the finger. This will expose 
the tendon, but it must be recognized that in this location the extensor 
tendon bears no resemblance to the same tendon on the dorsum of the 
hand. Instead of being a white, shiny, rounded band, it is thin and 
translucent and resembles a heavy layer of fascia. It is impossible to 
demonstrate a sheath or to distinguish the long tendon from the lateral 
aponeurosis. Fine chromic gut should be used to suture this thinned- 
out tendon to the terminal phalanx. The hand is put up with the 
fingers extended, and movement is allowed after about two weeks. In 
the old cases with marked bone changes, amputation of the terminal 
phalanx may be advisable. 



CRUSHING INJURIES OF THE FINGERS. 

These injuries are very common and of such infinite variety that a 
detailed description of the various injuries which may occur is practi- 
cally impossible. The lesions include compound fractures and disloca- 
tions of the bones, with and without rupture, and laceration of the 
tendons, arteries, and nerves. The treatment requires foresight and 
judgment, based upon the general principles referable to the surgery 
of this region. 

In injuries to the fingers conservation of function is to be kept in 
view, although occasionally a good anatomical result may be of more 
importance than good function. This is especially so in girls and 
women who are not obliged to do manual labor and in whom the 



296 



INJURIES OF THE ARM AND HAND 



deformity due to an amputated finger may cause such mental suffering 
as to give rise to a persistent neuresthenia. 

Treatment. — In all cases of crushing injuries to the fingers, the surgeon 
has to decide between immediate suture and the open antiseptic treat- 
ment as used in war surgery. In spite of the recent war experiences, 
it is believed that in civilian practice most injuries of this sort will do 
better if sutured. In machine-shop injuries, where the fingers are 
extensively crushed, excellent results are seen after primary suture. 
In accidents occurring about stables or in the streets where highly 

infectious dirt is ground into the 
tissues, the treatment should ap- 
proach the open method. 

In most cases especially in work- 
men, it is a good rule to sacrifice 
length of the fingers in order to 
obtain function, and to preserve 
the length of the thumb even at 
the expense of stiffness or deform- 
ity. As a rule only the almost 
completely separated fragments 
should be excised. The skin and 
wound should be well swabbed 
with tincture of iodine (one-half 
strength), the lacerated surfaces 
approximated as closely as pos- 
sible and sutured. A dry dres- 
sing should then be applied. In 
the application of iodine it is im- 
portant to enter every nook and 
cavity until the entire denuded 
area and skin surface have been 
covered. If, on the other hand, there is extensive laceration with 
very evident infection associated with multiple fractures or disloca- 
tions, and a functional result is especially desired, immediate amputa- 
tion is indicated. 

When the end of the finger is involved, the utmost care should be 
taken to preserve the matrix of the nail. A nail on the end of the 
finger, no matter how deformed the nail may be, greatly adds to the 
usefulness of the finger, this being especially true for the thumb and 
index finger. 

Fracture of the Nail. — Fracture of the nail occurs frequently as a 
result of injury to the tip of the finger. It is most often a longitudinal 
split, but transverse and multiple fractures may occur. The nail and 
tip of the finger should be painted with tincture of iodine, the solution 
being carefully introduced into all crevices. Portions of the nail 
which can be removed easily are cut away, and the wound is dressed 
with a dry dressing. A tin guard for the finger tip, or other protection 




Fig. 198. — Amputation of the fingers by 
the racket-shaped incision and by antero- 
posterior flaps. (Ashhurst.) 



CRUSHING INJURIES OF THE FINGERS 297 

against injury, is an added comfort to the patient and an aid to repair. 
After healing has begun it may be necessary to remove some of the 
fragments of the injured nail, in order to prevent deformity of the 
growing nail. In dressing these wounds care should be taken not to 
tear off portions of the nail in removing the gauze. If infection 
occurs the dressing should be changed to one that is wet and mildly 
antiseptic. 

Subungual Hemorrhage. Frequently the only evident result of a 
blow upon the finger is a hemorrhage beneath the nail. Only a portion 
of the nail may be involved, or the entire nail may be lifted from its 
bed, the space being filled with dark blood. The nail is usually tender 
on pressure, but unless there is infection, there is no spontaneous pain 
after the first day or two. 

Treatment.— The treatment varies according to the extent and situa- 
tion of the hemorrhage. Where the hemorrhage is small and occupies 
the mid-portion of the nail, the nail over the area of the hemorrhage 
should be scraped thin until a sufficient hole is formed to allow the 
evacuation of the blood. This procedure should be carried out under 
aseptic conditions. A sterile dressing should be kept on the finger for 
a few days until the loosened portion dries up, after which no further 
treatment is necessary. When the hemorrhage is situated under the 
distal portion of the nail, all the loose portion of the nail should be 
trimmed away. When the hemorrhage involves the proximal portion 
and is extensive enough to loosen the root of the nail, the nail should 
be removed entirely. In a great many cases the entire nail is loosened 
from its bed and is only held in place by the firm attachment of the 
skin around the borders of the nail. In these cases the nail can be 
removed without pain by introducing one end of a pair of scissors and 
cutting away the attached skin, avoiding any pressure toward the 
nail-bed and keeping close to the edge of the nail. Where a part of 
the nail to be removed is attached to its bed, a whiff of gas should be 
given because of acute sensitiveness. If this is impracticable local 
anesthesia may be used. The removal of the nail is accomplished in 
the following manner: The point of the knife is inserted between the 
nail and its bed at the tip of the finger, the blade of the knife being 
parallel to the flat surface of the nail. Much in the same manner as an 
apple is pared, the nail is separated from its bed for about one-half the 
exposed portion of the nail. It is then grasped with an ordinary artery 
clamp, the long axis of the clamp being at right angles to the finger, 
and the nail rolled back on itself in the manner of opening a can with a 
"key" opener. This method avoids any injury to the matrix of the 
nail. In all operations on the nail, careful surgical technic should be 
obtained. 

After the nail has been removed the surface may be painted with 
tincture of iodine, a piece of rubber tissue 1 about the size of the nail 

1 The rubber tissue prevents the dressing from becoming adherent to the matrix, and 
its small size allows free drainage. 



298 



INJURIES OF THE ARM AND HAND 



laid over the denuded area and a sterile dressing applied. After four 
or five days the denuded area will have become dry, after which all 
dressings may be removed. The usual time to grow a new nail is from 
sixty to one hundred days. 

Where the nail has only been partly removed, should secondary 
infection occur the balance of the nail should at once be excised. 

After the removal of the nail, all 
infections are treated the same as 
a simple infection of the finger. 

Laceration and Compound Frac- 
ture of the Finger Tip.— This con- 
dition is frequently seen, and may 
occur alone or combined with the 
injuries just described. The crush- 
ing force may cause only a splitting 
of the pulp of the finger without 
fracture; the injury may be asso- 
ciated with fracture; or, in other 
cases, laceration may be so exten- 
sive as almost to result in trau- 
matic amputation of the tip of the 
finger. 

For the mild cases, where there 
is only a slight, superficial lacer- 
ation of the skin, the finger is 
painted with iodine and a dry 
dressing applied. 1 

In the more severe cases, with 
extensive laceration of the skin 
and fracture of the terminal pha- 
lanx, the wound should be well 
swabbed with tincture of iodine 
as described above and the frac- 
tured ends of the phalanx approxi- 
mated, any small, loose fragments 
being removed. The lacerated 
edges of the skin are sutured with 
fine horsehair sutures, the loop of 
the suture being made as small 
as possible so as not to interfere 
with the blood supply. A strip of gauze, soaked in 1 per cent forma- 
lin solution, is wrapped about the finger in such a manner that mod- 

1 Occasionally, cases are seen where there has been no laceration of the skin, but which 
after a few days become cold and lifeless, part of the tip of the finger sloughing away 
after a week or more. This has been explained by the fact that the exudation in the tip 
of the finger is confined by the tough skin and nail, causing a pressure which interferes 
with circulation. Some surgeons advise incision of the finger tip in severe contusion 
without laceration. This form of treatment is still on trial. 




Fig. 199. — Photograph of a cleft naij 
due to an old injury to the nail matrix. 
This injury occurred in a postman many 
years previously. During winter the 
cleft would extend to the base of the nail 
and remain wide open; during summer 
with improvement in the circulation the 
cleft would almost close. To avoid a 
"cleft nail" an incision should be made 
as shown in A. (Brewer.) 



CRUSHING INJURIES OF THE FINGERS 299 

erately firm pressure is made. This dressing is allowed to dry and 
serves as a splint for the injured finger. For the first ten days a finger 
splint may be applied outside the dressing for additional protection. 
This dressing should not be changed for three or four days, nor should 
a wet dressing be applied unless there is evidence of infection. It is 
surprising what good results follow careful attention to these cases. 
It is not infrequent to see complete union follow an injury in which 
the end of the finger was attached by only a narrow strip of skin less 
than a quarter of an inch wide. 

The stitches are removed on the seventh or eighth day and if at this 
time evidence of a subcutaneous collection of blood is present, the fluid 
may be released by the insertion of a probe at some point in the line of 
suture. The attempt to secure union should be abandoned only when 
there are frank evidences of suppuration. 

Traumatic Amputation of the Fingers.— In clean-cut amputation, 
in which the end of the bone does not project, the wound should be 
cleansed with tincture of iodine and a dry dressing applied. After a 
few days the dry dressing should be changed to a boric ointment 
(made with vaseline) dressing, or the stumps may be covered with 
strips of sterile rubber tissue. Either of these measures will prevent 
adherence of the gauze to the cut end of the stump, the removal of 
which is extremely painful. If the amputated end of the finger is not 
crushed and mangled, and too much time has not elapsed since the 
accident, an attempt may be made to graft the amputated finger in 
place. This is only rarely successful; but, on the other hand, even if 
unsuccessful, it is seldom followed by untoward 1 complications. The 
amputated part should be well washed in sterile, saline and painted with 
weak iodine, the excess of which is removed with alcohol. The edges 
are slightly freshened and the skin sutured to that of the stump, with 
small horsehair sutures. Success is largely due to the proper approxi- 
mation of the edges of the skin. If, after a week, there is no evidence 
of returning circulation in the grafted part, the attempt should be 
abandoned and the graft removed. 

It is seldom, if ever, advisable to remove a portion of a bone in order 
to secure a sufficient skin-flap for primary closure of the wound in a 
clean-cut traumatic amputation. If the cosmetic results are likely 
to be unsatisfactory, it is better to wait and perform a secondary 
operation at a later date. Healing is usually complete in from four to 
six weeks. 

Extensive Crushing of the Fingers.— The general principles men- 
tioned above are especially applicable here. The skin of the fingers 
and hand is painted with tincture of iodine, the wound is opened up, 
and all corners and recesses inspected and swabbed with weak iodine 
tincture (3 per cent) under general anesthesia, if necessary. 

Loose splinters of bone should be removed, and dirty and discolored 
tags of fat and fibrous tissue excised. The bone fragments and tendons 



300 



INJURIES OF THE ARM AND HAND 



are brought together, and the skin edges closely approximated with 
fine sutures. It has been urged to leave wounds of this type widely 
open, but this is unnecessary unless there is infectious material in the 
tissues. After the suture is completed, the fingers are wrapped with 
gauze soaked in formalin (1 per cent), in such a manner that the gauze 
forms a stiff, firm binding about the fingers. The entire hand is now 
placed in cotton upon a palmar splint, and it is not dressed before the 
second or third day, unless there are signs of infection. During the 
first dressings it is better not to remove the dry layer of blood-soaked 
gauze which lies directly against the wound, unless there are signs of 
infection. The removal of this layer simply starts fresh hemorrhage 
and opens avenues for infection. If the gauze is dry, it offers a poor 
medium for infection ; while if it is moist it favors the growth of micro- 




Fig. 200. — Fingers amputated by a card-cutter. 



organisms, and should be removed. Continuous wet dressings are 
rarely advisable during the early stages of healing. 

If infection makes its appearance, the pus cavities may be drained 
as indicated, and a wet, antiseptic dressing applied. Extensive, 
purulent infiltration may be an indication for amputation. After 
healing is complete, plastic operations may be performed, if necessary, 
upon the tendons for the restoration of function. 

In the most extensive injuries in which primary amputation is 
indicated and in older cases where amputation has become necessary 
because of infection, or for other causes, the operation performed 
depends to a large degree upon the extent of the injury and the fingers 
involved. In case of the index and little finger the amputation should 
be performed so as to leave a stump which is well covered with skin; 



CRUSHING INJURIES OF THE FINGERS 301 

a long palmar and a short dorsal flap is preferred. 1 The amputation is 
made either through the first or second phalanx or the first phalangeal 
joint, the palmar skin being turned back to cover the end of the bone. 
A stump consisting of as little as a third of the first phalanx may be of 
value. When the entire finger is to be removed, it is advisable to 
disarticulate the finger at the metacarpophalangeal joint. Amputa- 
tion-flaps should be sutured with fine horsehair interrupted sutures, a 
small rubber tissue drain being inserted at one corner of the wound. 

In the case of injury to the ring and middle fingers, the treatment is 
somewhat different. Unless the entire first phalanx can be saved, it is 
usually advisable to amputate the entire finger, and for cosmetic 
purposes the head of the corresponding metacarpal bone. If the 
finger is amputated at the metacarpophalangeal joint, the gap between 
the fingers is very noticeable; while if the head of the metacarpal is 
removed at the same time the space takes on the appearance of the 
normal space between the fingers. This operation is indicated when 
a good cosmetic result is desired at the expense of some of the strength 
of the hand. It is performed as follows : An oval incision is made, the 
posterior and upper end of the oval being one-half inch above the joint, 
while the anterior and wider end is on the palmar surface of the finger 
about one-half inch below the joint. If more room is needed, the 
incision may be enlarged by a longitudinal incision upward along the 
line of the metacarpal bone. 

The anterior flap is dissected back, the tendons and nerves are cut 
above the level of the joint, and the neck of the metacarpal bone is 
divided in an oblique direction, either with a fine saw or a cutting 
forceps. The vessels are tied with fine catgut, and the wound edges 
are brought together with horsehair sutures. 

If it is desired to save the head of the metacarpal (in a workman this 
may be necessary as a measure to preserve the strength of the hand), 
the incision is best made with a long anterior flap. The incision begins 
on the dorsum immediately over the articulation and extends trans- 
versely into the cleft between the adjoining fingers, the midpoint 
between the dorsal and palmar surfaces. From both ends of this 
incision, longitudinal incisions pass along the lateral surface of the 
finger to a point about the middle of the first phalanx. The distal 
ends are connected with a transverse incision across the palmar surface 
of the finger. The anterior flap is dissected away from the bone, the 
tendons and nerves divided at the level of the joint, and the finger 
sharply flexed so that the posterior ligaments may be cut with a pair 
of sharp scissors. Continuing the flexion, the anterior ligaments are 
easily cut and the finger removed. The vessels are tied, and the 
anterior flap is sutured over the head of the metacarpal bone. 

1 In all cases where only the tip of the finger is involved the nail should be saved if 
possible. 



302 INJURIES OF THE ARM AND HAND 

Amputation of the thumb may be required in crushing injuries. The 
general principles of conservation, as outlined for the fingers, are 
especially applicable in the case of the thumb. Never remove any 
portion of the thumb that can possibly be saved. Make the flaps from 
the palmar, dorsal, or lateral surfaces ; but in any event save as much of 
the bone as can be covered with skin. Even a short piece of the first 
phalanx will be of great value in the subsequent use of the hand. When 
the conditions permit, the long palmar flap gives the best results ; but 
none of the bone should be sacrificed in order to secure a satisfactory 
flap. Particularly in the thumb are conservative methods indicated, 
even if there will be probable ankylosis of one or both joints. 



CHAPTER X. 
ACUTE INFECTIONS OF THE UPPER EXTREMITY. 

ERYSIPELAS AND ERYSIPELOID. 

Erysipelas has already been described in detail. It is infrequent 
upon the upper extremity, but it occurs occasionally as a complication 
of wounds. It is likely to be less severe than on the face and is usually 
accompanied by less toxemia. The treatment is the same as for ery- 
sipelas occurring on the face. 

Erysipeloid.— This affection described by Rosenbach, a not uncom- 
mon inflammatory disease somewhat resembling erysipelas and usually 
occurring on the fingers and hands, occurs almost without exception 
in those who handle fish and meat, such as fish dealers, butchers, etc. 
The disease is characterized by a spreading area of inflammation, 
which shows a slowly advancing border and is associated with slight 
sensations of pain and heat. The disease begins at the site of a slight 
scratch or abrasion and advances about 0.5 to 1 cm. daily, the earlier 
affected areas healing as the advance continues. The rapid advance 
and constitutional symptoms usually seen in erysipelas are absent. 
The advancing zone of erythema is sharply defined and slightly raised 
above the surrounding skin, while the area where the disease is sub- 
siding shades from dull red to normal skin. It somewhat resembles 
ringworm, but there is no scaliness of the skin. 

Rosenbach has described a specific bacillus which he claims to have 
isolated from the lesion and which he found often in decomposing fish. 
In several of our cases cultures were made from incisions along the 
advancing border, and small pieces of tissue were removed which 
showed no growth in the cultures. Gilchrist, in a study of several 
hundred cases, suggested that the condition might be due to the 
inoculation of an undetermined ferment. 

Treatment.— Two points must be remembered in the treatment of 
erysipeloid infection: (1) That there is practically never pus forma- 
tion; (2) that the disease is usually self-limited, lasting about two weeks. 
When first seen it resembles an ordinary infection from a cut or abra- 
sion, and at this period many cases are needlessly incised. Ichthyol 
ointment and unguentum Crede have both been advised, but do not 
seem to have an active influence upon the control of the disease. In 
recent cases we have seen good results follow painting of the surface of 
the erythematous area with carbolic acid (95 per cent), which is washed 
off immediately with alcohol. Following this a wet boric acid dressing 



304 



ACUTE INFECTIONS OF THE UPPER EXTREMITY 



is applied. In most cases, regardless of the treatment used, the area 
of inflammation gradually becomes less marked and disappears about 
the tenth or twelfth day. 

RINGWORM (TRICHOPHYTOSIS). 

A common form of inflammatory affection of the hands, which 
occasionally comes under the surgeon's care, is ringworm. In its 
typical form, the easily recognized, scaly, sharply outlined area of 
inflammation is so well known that detailed description is unnecessary. 
In the less frequent papular or vesico-papular variety, the diagnosis is 
more difficult. A pustular condition is rarely present except in the 
palm where the skin is thick. In the papular or papulo-pustular 
type there may be a considerable thickening of the skin. Microscopic 
examination will confirm the diagnosis in doubtful cases. 1 




Fig. 201. — Chronic lineal dermatitis of the forearm, following extensive ringworm 
infection of the palm. Duration, four months. 

Treatment.— In the simple form, cleanliness and daily applications 
of tincture of iodine will result in a rapid cure. In the more obstinate 
cases, sulphur ointment, white precipitate ointment, and strong 
solutions of mercuric chloride (1 to 3 grains to the ounce) may be used 
with beneficial results. When available the roentgen rays will cure all 
types of ringworm. Chrysarobin ointment, 6 per cent, may be tried 
if other remedies fail and the roentgen ray is not available. 



RINGWORM OF NAILS (TRICHOPHYTOSIS UNGUIUM). 

Ringworm involvement of the nail is frequently seen on the fingers, 
less frequently on the toes. It may involve a single digit, but it is 
more often found to involve a number. The nail becomes rough, 
cracked, and opaque, and on raising its edge from the bed the cuticle 

1 See Ringworm of the Plantar Region. 



PYOGENIC INFECTION OF THE UPPER EXTREMITY 305 

is separated from the nail-root and becomes very much thickened and 
discolored. There is no pain, except where a secondary infection, 
which is common, takes place. As the same appearance is found in 
psoriasis and several other diseases, it is impossible to make a positive 
diagnosis without the aid of the microscope. 

Treatment.— Roentgen-ray treatment has proved to be the most 
efficient treatment for ringworm, psoriasis, and similar involvements 
of the nails. Where the roentgen ray cannot be used, tincture of ferric 
chloride has been found successful in many cases; and an old remedy 
that we have seen successfully used is common writing ink. Tincture 
of iodine and other antiseptics have not proved satisfactory in our work. 

PYOGENIC INFECTION OF THE UPPER EXTREMITY. 

Infection of the hand developing into cellulitis or abscess is one of 
the most frequent minor surgical conditions which the physician is 
required to treat. In Vanderbilt Clinic, of 2000 consecutive cases, 
approximately 5 per cent were due to infection of the fingers or hand. 
Because the hands are exposed to injury, wounds both large and small 
are of frequent occurrence; and, because the hands are frequently in 
contact with highly infective materials, infection of neglected wounds 
occurs in a large percentage of all cases. 

The importance of complete preservation of function in the fingers 
and hands, makes early and skilful management of such infections far 
more desirable than in other parts of the body. In almost every case 
of acute pyogenic infection of the hand there are associated a collection 
of pus (abscess), diffuse inflammation of the cellular tissue (cellulitis), 
and inflammation extending through the lymphatics (lymphangitis). 
Depending upon the location of the pus and upon the virulence of the 
causative agent the picture of infection may vary. In some cases there 
may be extensive abscess formation with slight or unrecognizable 
cellulitis or lymphangitis, and in other cases either of the two latter 
types of inflammation may be emphasized with only an apparently 
insignificant collection of pus. 

In addition to the above, infection of the hand may be complicated 
by an associated osteomyelitis, arthritis, or tenosynovitis. The pres- 
ence of any one of these latter complications adds to the severity of the 
disease, and makes the ultimate prognosis much less favorable. For 
convenience, the various conditions may be discussed separately; 
but it must be clearly understood that in the three cardinal types of 
infectious process, abscess, cellulitis, and lymphangitis, there is no 
distinct line of demarcation. 

In practically every case there is a point of entrance for the infectious 
material somewhere on the hand or arm. It would be well in treating 
hand infections if the surgeons could forget that infection by the blood 
stream is a possibility. So few such cases occur as to make them prac- 
tically surgical curiosities. If the hand is carefully examined, a small 
20 



306 ACUTE INFECTIONS OF THE UPPER EXTREMITY 

scratch or partially healed laceration can almost always be found in 
those cases in which a self-evident portal of infection is not at once 
apparent. Often the primary focus is found apparently completely 
healed, but more frequently the removal of a small crust shows a minute 
drop of pus. Any of the pyogenic bacteria may act as the exciting 
cause. 

Lymphangitis of the Hand.— This affection is closely akin to cellu- 
litis, but the inflammation begins more superficially. It is charac- 
terized by redness of the skin and of the lymphatics, forming parallel 
red lines extending from the region of the focus of infection to the 
hand and up the forearm. There is little swelling, and often little or 
no pain. The lymph nodes, either the epicondylar or axillary, are 
likely to be involved early and become evident as large, painful lumps 
which are very tender. In a fairly large number of cases, the presence 
of a large, tender gland in the axilla or at the inner side of the elbow 
is the first sign which draws attention to the lymphangitis of the hand. 




Fig. 202. — Abscess on the back of the wrist, with lymphangitis and axillary involve- 
ment. Duration, four days. 

Treatment.— The source of the primary infection should be searched 
for, and, when found, freely drained. A wet dressing is then applied 
to the infected area and a similar dressing to the enlarged glands of the 
arm or axilla. Most cases recover rapidly under this treatment. In 
some cases the lymphangitis disappears, but the adenitis persists and 
must be incised at a later date. A few cases go on to cellulitis which 
must be treated as outlined below. 

Cellulitis.— This affection is associated with a diffuse swelling, which 
may be localized to a single finger or may involve the entire hand and 
arm. On the dorsum of the hand the swelling may be extensive, but 
on the palmar surface, because of the tough, unyielding character of 
the skin, the swelling is much less noticeable. The fingers, when the 
inflammation is located in the palm, are held in a position of partial 
flexion in order to relax the tissues and thus to diminish pain due to 
pressure on the nerves. Extension and flexion are painful. 

On the dorsum of the hand, where the various stages of infection are 
easily recognizable, there is first a period of edema associated with 
little pain and no tenderness; when the inflammation is more advanced, 



PYOGENIC INFECTION OF THE UPPER EXTREMITY 307 

the edema is harder and the swollen area becomes indurated and tender; 
at the location of abscess-formation, the tenderness is most acute and 




Fig. 203. — Soft edema of the right hand and wrist. No point of tenderness. Swelling 
subsided in three days without incision. Resembles type of swelling occurring after 
insect sting. 

the induration is more marked and extensive. When the abscess is 
large enough, there may be an area of fluctuation, but in acute cases 
fluctuation is usually masked by the surrounding induration. 




Fig. 204. — Palmar abscess in a child. Pus superficial to palmar tendons. Duration, 

six days. 



In the palm these changes are less evident because of the dense 
fascia and thick skin. Tenderness is early and extensive, but if the 



308 ACUTE INFECTIONS OF THE UPPER EXTREMITY 

examination is made carefully, the abscess-formation can be detected 
by the increased tenderness at that point. 




Fig. 205. — Deep palmar abscess in an infant. Superficial incisions shown were useless. 

Duration, nine days. 

In all cases the outlines of the hand are changed, the lines of the skin 
are obliterated, and the function of the hand is limited. 

So-called "pointing" of the abscess is usually late in making its 
appearance. 




Fig. 206. — Acute infection of the finger. Duration, eight days. No tendency to 
spread to the hand. Subcuticular pus cavity involves entire finger. Tendon not 
involved. Rapid recovery following incision. 

Treatment.— It cannot be too strongly emphasized that the only form 
of treatment which is of any value in cellulitis of the hand is incision 
and drainage. 

Only in those cases which are due to open infected wounds, and where 
the cellulitis is limited and drainage is free, is there justification for 
conservative treatment. 



PYOGENIC INFECTION OF THE UPPER EXTREMITY 



309 



In most cases of cellulitis, if a careful search is made, a point of 
infection can be located, either a small puncture wound, a laceration 
which has partially healed, or a small cut covered with a dry crust. 
If any of these is present, it should be freely opened, even if there is 
little or no local tenderness. If such a portal of infection is not found, 
the incision should be made at the point of the greatest tenderness; 
if the point of greatest tenderness cannot be definitely located, the 
incision should be made at the point where the infection apparently 
began. In a few cases there will be doubt as to the presence of pus, 
and, consequently, of the advisability of incision. In other cases there 
is no evident localization of pus. In all such cases where the diagnosis 




Fig. 207.— Severe cellulitis of the 
hand. Duration, three weeks. 



Fig. 208. — Dorsal view of Fig. 207, showing 
the wounds healed, although the cellulitis is 
still active. 



of cellulitis is reasonably certain, an exploratory incision is not only 
justified but strongly indicated. Don't wait until the abscess "points." 
While the above may be considered too radical, the writer is cer- 
tain that, in the hand, the results are much better after early incision 
than after conservative treatment. While it may be true (although 
debatable) that healing is more rapid after the incision of a fully 
developed abscess than after incision during the early stages, the 
results of neglected cellulitis of the hand are so dire and the complica- 
tions are so severe that the primary indication is the immediate 
institution of any measure, or measures, which will tend to stop the 
spread of infection. On the dorsum of the hand where there is little 
or no induration and no localized tenderness, it is sometimes justifiable 



V 



310 ACUTE INFECTIONS OF THE UPPER EXTREMITY 

to apply a large wet dressing and support and wait for a time, in order 
to determine where the infection started. The multiple incisions 
through the edematous dorsum of the hand seldom do much good and 
frequently lead to deformity. It must be emphasized, however, that 
the swollen and edematous area over the dorsum of the hand is fre- 
quently due either to an infection in the palm or between the fingers. 
We have frequently seen ineffective incisions made on the back of the 
hand where the swelling was most evident, and the point of abscess- 
formation on the palm entirely disregarded because the tough palmar 
fascia had prevented any apparent swelling. 

The length of the incision depends largely on the severity of the 
infection and the extent of the process. Small puncture incisions have 
no place in the surgery of cellulitis. The incision made for drainage 
should be large enough to allow the purulent discharge to escape 
freely, thus preventing the spread of infection, and at the same time 
relieving tension. Frequently cases apply to the hospital for treat- 
ment suffering from well-developed cellulitis, showing a small incision 
not more than one-fourth of an inch in length, firmly plugged with a 
small gauze wick. Such treatment is worse than nothing, because it 
lulls both the patient and the physician into a sense of false security. 
If an abscess is found, it should be opened widely and kept open. An 
incision less than half an inch in length is never practicable except 
in very superficial infections. It has been our practice to enlarge the 
palmar incision in serious cases so that an elliptical opening resulted, 
not less than half an inch in length, and about one-fourth of an inch 
wide at the widest part. Such an incision allows for free drainage 
without the necessity of inserting drainage material. The location 
of the incision varies with the location of the infection. In general, 
longitudinal incisions are preferred both in the fingers and the hand. 
On the palmar surface of the fingers the incision is made in the midline, 
avoiding the fold of the skin at the location of the joint; on the dorsum, 
lateral incisions are usually preferred, avoiding the skin over the 
joints. At the end of the finger, a curved incision in a plane parallel 
to the nail gives the best results. 

On the palm the incisions are ordinarily made parallel to the long 
axis of the metacarpal bones down to or through the palmar fascia, 
as the individual case may require, care being taken not to injure the 
superficial or deep palmar arches. Occasionally in deep palmar inci- 
sions, a large branch of the arch is cut, causing considerable bleeding 
and being interpreted by those of slight experience as a division of the 
palmar arch. The bleeding in such cases soon stops and very rarely 
requires either packing or ligature. On the back of the hand the 
incisions are made in the same direction, one or more incisions being 
made according to the severity of the infection. 

Incisions on the palm are likely to close rapidly, so that in this 
position the lateral enlargement of the opening as noted above is 
important; while on the dorsum of the hand, where the loose skin 



Pyogenic infection of the upper extremity 3il 

allows the edges of the wound to remain widely separated, the simple 
incision usually provides adequate drainage. If the infection has 
already invaded the forearm, large, multiple incisions should be made 
at once and free drainage instituted. 

Drainage is an important adjunct to treatment. The choice of the 
type of drainage material depends entirely upon whether or not it 
provides free drainage. Dry gauze is likely to be unsatisfactory. 
It becomes impregnated with blood and serves only as a plug which 
closes the opening. We have for years been using gauze drains 
smeared with boric ointment or any other form of antiseptic ointment. 
This oily covering prevents adhesions between the wound and the drain 
and mechanically acts as an aid to drainage. When gauze is used, care 
should be taken to introduce the gauze, not as a packing for the cavity 
or as a plug for the opening, but such a manner that the wound is held 
open. 

A small, soft, fenestrated rubber tube is a fairly satisfactory form of 
drainage material. Its chief disadvantages are that it becomes easily 
dislodged from shallow cavities, which necessitates frequent redressings 
of the wound and that it may cause pressure on the tendons with 
necrosis. 1 Rubber tissue drains may be folded so as to form a fairly 
satisfactory drain, but as commonly used they are made in the shape 
of small drains three or four layers in thickness and, consequently, 
they do not hold the wound open widely enough to allow sufficient 
drainage. 2 

After the abscess has been opened and the drain inserted, a wet 
dressing should be applied. The type of solution depends largely on 
the preference of the surgeon, but it is well established that a wet 
dressing, to be serviceable, must be kept wet constantly. A large, 
loose dressing should be applied well beyond the area of cellulitis, and 
the patient told to keep the dressing constantly wet. Far too fre- 
quently patients are told to keep a dressing wet and then given a small 
bottle of solution with which the bandage is supposed to be kept wet. 
Unless at least a quart of solution is given, it is absurd to believe that 
the dressing can be kept sufficiently wet for more than a few hours. 

A practical method, which has been used successfully in many cases, 
is the intermittent boric acid bath. The wound having been dressed, 
•the patient is given a few ounces of powdered boric acid and told to 
prepare a solution by adding one level teaspoonful of boric acid to a 
pint of boiling water. After this has been cooled, he is instructed to 
soak the hand, without removing the dressing for ten minutes every 
two hours. It is found that this treatment keeps the dressing suffi- 
ciently wet during the entire day. If, on the other hand, the patient 
is told merely to keep the dressing wet, he will rarely keep it much more 

1 A good working rule which we have followed is to use gauze drains smeared with 
ointment in the hand, and rubber tubes in the fleshy parts of the forearm. 

2 Some years ago Gerster drew attention to the fact that abscesses, deep or super- 
ficial, heal more quickly if they are converted into a conical-shaped opening, the abscess- 
cavity representing the apex of the cone. 






312 ACUTE INFECTIONS OF THE UPPER EXTREMITY 

than moist unless an extension of the inflammation has impressed upon 
him the importance of a continuous wet dressing. The continuous 
bath which was so in vogue a few years ago has been carefully tried 
out by us in cases showing infections of both hands, one hand being 
treated in the continuous bath and the other in a loose wet dressing, 
with a splint applied to keep the part at rest. In almost every case 
the hand treated in the continuous bath healed less rapidly than the 
other. 

Many other solutions have been advised. Sir Almoth Wright has 
advised the use of hypertonic salt solutions (5 to 10 per cent) both for 
irrigations and for continuous wet dressings. Dilute hypochlorous 
acid (0.5 per cent) the so-called "Dakin's solution," has been advised 
by Carrel on the basis of war experiences. 1 Among others, the follow- 
ing solutions have been advised: bichloride of mercury (1 to 5000), 
alcohol (20 to 50 per cent), potassium permanganate (1 to 5000). 
Lambert's recent experiments, which demonstrated that iodine, in a 1 
to 1000 watery solution, killed staphylococci in vitro without killing 
tissue cultures in the same solution, while many of the other antiseptics 
caused equal injury to the bacteria and the tissue cells, would seem to 
indicate that dilute iodine solutions have surgical value hitherto not 
appreciated. From a clinical standpoint watery tincture of iodine 
solutions (1 to 200) have been used in purulent infections in some of the 
large New York hospitals for the past ten or fifteen years. It was 
found that cases so treated seemed to show less discharge and the 
dressings were sweeter than when treated with other solutions. We 
have used this solution regularly in certain cases of purulent infection 
for the last twelve years. 

In certain cases a continuous irrigation should be resorted to. 
Irrigation gives the most satisfactory results. Soft, rubber catheters 
are introduced into the recesses of the pus pockets and warm solutions 
allowed to flow continuously through the catheter. If this treatment 
is to be adequately carried out, the patient must be in bed and a nurse 
must be constantly in attendance. It is rarely advisable to allow the 
patient or an untrained attendant to attempt to arrange the irrigation 
apparatus. Dakin's solution is most satisfactory when used in this 
manner. 

If the pain and swelling continue to increase after twenty-four hours 
have elapsed in spite of satisfactory dressings, it is probable that the 
incisions have not been extensive enough, or that a complicating 
suppurative tenosynovitis or osteomyelitis exists. In all cases the 
hand and arm should be placed at rest either on some form of a splint, 
or on a pillow if the patient is confined to bed. 

How long should the wet dressing be continued ? In general it may 

1 There are several easily prepared chlorine solutions on the market which approxi- 
mate the solution advised by Dakin. In general they are not considered as satisfactory 
as the original solution but owing to the convenience of their preparation they are more 
widely used. 



PYOGENIC INFECTION OF THE UPPER EXTREMITY 313 

be stated that as a rule the wet dressing should be removed just as 
soon as there is no danger of the infection extending farther. In 
practice, it is hard to say just how long this period is. Usually after 
about five days the swelling has subsided, and the hand shows only a 
discharging sinus and granulating areas. This sinus will heal much 
more rapidly when the wet dressing is discontinued and the granulating 
area dressed with some stimulating application, such as balsam of Peru ; 
but cases are occasionally seen in which the wet dressing must be 
continued for two weeks or longer. In practice, the wet dressing may 
be discontinued when the wound appears to be discharging freely and 
the swelling is decreasing. The hand should be closely watched, and 
if the pain and swelling recur, the wet dressing should be at once 




Fig. 209. — Tuberculosis of the skin in a butcher. Duration, two years. History of 
intermittent healing and breaking down. 

reapplied. Patients should be warned that the condition may become 
worse and told that any increase of pain or swelling requires the atten- 
tion of the surgeon without delay. 1 When Dakin's solution was used 
in war infections it was customary to check the effectiveness of the 
dressing by microscopic examination of the discharge. Each day when 
the wound was dressed a smear was made which was stained and 
examined under the oil immersion lens for bacteria. At the beginning 
of the treatment hundreds are seen in each field but as satisfactory 
progress is made the numbers steadily decrease. When less than one 
per field is found the wound is considered sterile. 

During the stage of healing, heat and light rays from the ordinary 
incandescent light have been found of considerable value as a thera- 
peutic measure. High candle-power lamps with reflectors are manu- 
factured especially for injuries of this type. In the stiffness which 
follows healing, baking, massage, and active and passive motion have 
all been found of value. 

1 See also Treatment of Infected Wounds. 



3l4 ACUTE INFECTIONS OF THE UPPER EXTREMITY 

Abscess of the Hand.— This affection occurs associated with cellu- 
litis, and the treatment is the same as for cellulitis. Occasionally, a 
case first comes under treatment showing a well-localized abscess with 
little surrounding cellulitis. Such an abscess should be widely incised 
and drained and treated with the same care as though spreading 
cellulitis were present. 

Suppurative Tenosynovitis.— Suppuration of the tendon sheaths 
usually occurs as a complication of cellulitis, although in some cases it 
occurs as an isolated process. Infection is ordinarily introduced 
through a wound which penetrates the tendon sheath; but in diffuse 
cellulitis of the hand, infection may apparently spread by contiguity 
directly into the sheath. 

In order fully to understand the spread of purulent material along 
the sheath, a clear understanding of the location of the tendon sheaths 
of the hand is required. 

After wide experience in a teaching clinic and in the outpatient clinics 
of the New York Hospitals, it is the writer's opinion that many of the 
cases of suppurative tenosynovitis arise because the sheath is punctured 
with the hypodermic needle in the preliminary local anesthesia, or 
with the point of the scalpel in making an incision, causing thereby a 
direct inoculation of infectious material into the sheath. The frequent 
return of patients with an exacerbation of pain after a period of relief, 
indicates that this is a very real danger. He has for several years 
advised against deep infiltration in the neighborhood of the hand, 
using superficial or nerve-blocking anesthesia instead. For the same 
reason, he never makes a puncture incision. There is sometimes a 
serious effusion into the sheath, causing it to present very close to the 
surface. 

In every case of cellulitis, the possibility of involvement of the 
tendon sheath must be given due consideration. The swelling of the 
finger and hand causes such acute tension that a differential diagnosis 
between tenosynovitis and cellulitis is difficult or impossible. In 
involvement of the sheath with only slight cellulitis, the characteristic 
pain on movement of the fingers and the limitation of the swelling to the 
location of the tendon sheath are aids to diagnosis. However, these 
cases are so rare, that usually the definite diagnosis can be made only 
after incision. It is claimed that attempts to flex the fingers while 
they are held firmly in the extended position will cause acute pain 
when the tendon sheath is inflamed. 

The sheath of the flexor of the thumb extends upward to the wrist. 
The palmar sheath connects with the little finger sheath but does not 
connect with those of the other fingers, consequently, it is apparent that 
in the case of the little finger and the thumb, the inflammation is more 
likely to spread into the palm than in the case of the other fingers. 
However, it must be remembered that in inflammation in the synovial 
sheaths which do not communicate, suppuration may spread to the 
palmar sheath by contiguity. 



PYOGENIC INFECTION OF THE UPPER EXTREMITY 315 

The relation of the palmar fascia to the tendon sheaths is such that 
swelling is limited by the heavy fascia. In palmar abscess there may 
be considerably more swelling on the back of the hand, where the 
tissues are loose, than on the palm, where the fascia and thick palmar 
skin prevent swelling. 

The two palmar sheaths, the one surrounding the tendon of the 
flexor longus pollicis and the other surrounding the tendons of the 
flexors sublimis and profundus digitorum, extend upward into the 
forearm for an inch or more beyond the annular ligament. At this 
point the tissues are loose and fluid distention of the sheaths becomes 
plainly evident, even when it is not apparent on the palm. 




Fig. 210. — Photograph of the thenar swelling in an early abscess of the thenar space. 
The line of incision for drainage of the thenar space, or the space between the adductor 
trans versus and first dorsal interosseous, is also shown. (Brewer.) 

Symptoms.— The general symptoms associated with suppurative 
tenosynovitis are often of considerable severity. There are both 
fever (usually as high as 102° F.) and marked prostration. In untreated 
cases the suppuration may remain localized and finally rupture, either 
into the tissues, resulting in diffuse cellulitis, or externally, with a 
decrease of the general symptoms and local swelling. However, cases 
which rupture spontaneously rarely result in a complete cure. The 
drainage is usually insufficient, so that the process persists as a subacute 
inflammation, becoming more acute whenever free drainage is interfered 
with. Suppurative tenosynovitis is usually of long duration, and the 
prognosis for complete return of function is not good. After the acute 
inflammation has subsided, there is likely to be pain and stiffness of the 
affected tendon for some months and permanent disability is very likely 
to occur. 



316 



ACUTE INFECTIONS OF THE UPPER EXTREMITY 



Treatment.— Because of the extreme sensitiveness of the inflamed 
tissue and the necessity for careful exploration of the abscess-cavity, 
it is usually advisable to operate under general anesthesia. As 



mentioned above, there is also danger of spreading the infection to 
non-infected sheaths. 

Just as in any other collection of pus, the indication is for early and 
free drainage. The incision is made in a longitudinal direction, so as 
to cause the least possible injury to the important structures of the 
fingers and hand. 




Fig. 211. — A normal adult type. (Poirier.) 

The first incision should be made at the point of infection and should 
be about an inch in length. The tissues should be retracted, and the 
tendon sheath opened in a longitudinal direction. Pressure is now 
made at the upper end of the tendon sheath. If this causes an increased 
purulent discharge, the upper end of the tendon sheath should be 
opened by an incision in the palm about one inch in length, the center 
of the incision being located over the metacarpophalangeal joint. 
Similar incisions should be made distal or proximal to the primary 



PYOGENIC INFECTION OF THE UPPER EXTREMITY 



317 



incision, if required. The result is a series of two or three incisions 
over the region of the sheath, with bridges of skin left at the flexures 
of the fingers. It must be remembered that if the tendon sheath is 
laid open from end to end, the tendon is almost certain to slough. 
Such an incision is only justified in cases of very acute infection, such 
as cellulitis due to bacillus aerogenes capsulatus. 

In the case of the little finger and the thumb, the infection tends to 
spread rapidly to the palm. The palmar fascia is thick and tense, 
so that when a longitudinal incision is made, the fascia and thick skin 
of the palm tend to fall together and close the wound. For this 
reason it is better to enlarge the superficial incision through the skin 
and fascia by a short lateral incision, and then to continue the deep 
incision in a longitudinal direction. If the superficial palmar arch is 
encountered, it should be ligated 
and divided . There is least danger 
of nerve injury over the fourth 
metacarpal bone. In the case of 
the thumb, the incision should be 
made between the two heads of the 
flexor brevis hallucis, but should 
not be extended too far upward, 
because such an incision may divide 
the branches of the median nerve. 

If the suppuration in the palm 
is extensive, it may have extended 
above the annular ligament where 
it will be apparent as a swelling 
just aboA^e the wrist. In such 
cases another incision is necessary 
in the wrist. If the thumb is in- 
volved the incision should be made 
to the outer side of the tendon of 
the flexor carpi radialis, extending 
from the fold of the wrist upward 

for an inch or more. The median nerve lies close to this incision, 
and must be avoided. The incision being made to the outer side of 
the tendon in order to avoid the nerve, there is danger of injury to 
the radial artery which must be carefully avoided. Erosion of the 
artery may occur, with the possibility of fatal hemorrhage, and should 
be guarded against. 

In cases of infection of the sheaths of the digital flexors, the incision 
in the wrist should be made at a point to the inner side of the flexor 
carpi ulnaris and pass in through the natural line of cleavage between 
the pronator quadratus and the flexor tendons. The vessels, nerves, 
and tendons will be in front of this line of cleavage. In some cases 
both incisions are made so as to allow for through-and-through drainage. 
Flexion of the wrist keeps this cavity open. Drainage for any form of 




Fig. 212. — Localized abscess of the 
finger. Duration, five days. No tend- 
ency to spread. 



318 



ACUTE INFECTIONS OF THE UPPER EXTREMITY 



tenosynovitis may be best secured by the use of a gauze drain well 
smeared with ointment, as described under cellulitis. Theoretically, 
a rubber tube is the best drainage material ; but, in the hand, it is likely 
to press upon the vessels or nerves and result in injury, or upon a 
tendon and cause necrosis; moreover, it easily slips out of the wound 
and must be frequently reinserted. The wounds should be packed so as 
to hold the edges widely apart, without at the same time closing the 
mouth of the wound with drainage material. A wet dressing should 
be applied continuously, as described under cellulitis. 1 





Fig. 213 



Fig. 214 



Figs. 



213 and 214. — Showing perfect function after extensive incision of the palm and 
dorsum, care having been taken to conserve important structures. 



If the posterior tendon sheaths are invoked, the same method of 
treatment is used as in the palmar lesion. As the tendons are more 
superficial, the technical difficulties are less pronounced. 

Whenever possible, continuous irrigation with saline or mild anti- 
septic solutions is a valuable method of treatment during the acute 
stage. The irrigating pressure should not be more than that which is 
secured by hanging the irrigation jar 20 to 24 inches above the hand. 



1 The use of wet dressings and antiseptics has been discussed in detail under the 
Treatment of Infected Wounds and also under Cellulitis of the Hand. 



ARTHRITIS 



319 



After the acute stage has subsided, mild passive movements and 
massage may be given daily to prevent adhesions. 

When the wounds have entirely healed, there is likely to be con- 
siderable stiffness of the fingers and hand, partially due to disuse and 
partially due to adhesions. Passive motion, massage, baking, and 
counter-irritation, all act to increase the limits of movement of the 
affected fingers. The treatment must be persisted in for weeks or 
months. Occasionally it is advisable to break up the adhesions under 
general anesthesia. 

During the acute stage the hand should be carried in a splint to give 
the inflamed tissues a period of rest ; but after the acute inflammation 
has subsided, the splint should be discarded, even at the expense of 
some slight discomfort to the patient. Even during the acute stage, 
the fingers should be moved a little each day, in order to prevent 
adhesions. 




Fig. 215. — Suppurative arthritis. Carbuncle of the wrist penetrating the joint, with 

permanent disability. 



ARTHRITIS. 

Suppurative Arthritis.— This affection rarely occurs as a primary 
lesion. It is usually a complication of injury to the joint or cellulitis 
of the hand. The characteristic swelling and extreme pain on move- 
ment of the affected joint make the diagnosis comparatively easy. 
In cases where the swelling of the fingers and hand is great enough to 
obscure the joint-swelling, the diagnosis is more difficult. If the joint 
is inflamed severe pain will be caused by pressing the articular surfaces 
together in the long axis. A roentgenographic examination will often 
show distention of the joint-cavity and erosion of the articular surfaces. 
However, a negative roentgen-ray finding does not exclude arthritis. 

Treatment.— The joint should be opened by two lateral incisions and 
through-and-through drainage instituted. The joint should be 
irrigated with mild antiseptic solution, and superficial drainage insti- 
tuted in order to prevent closure of the wound. Through-and-through 
drainage with a soft rubber catheter has been used for many years, but 
its use should not be continued, because the catheter acts as a foreign 
body and tends to prolong the period of suppuration. 



320 ACUTE INFECTIONS OF THE UPPER EXTREMITY 

During the treatment the joint may be kept at rest with a splint 
or other form of fixation apparatus. In these cases passive motion is 
ordinarily not begun until the wound has been completely healed for 
several weeks and the evidences of pain and inflammatory reaction 
have largely disappeared. According to the recently advocated 
Willem's plan of treatment, early and persistent active mobilization 
combined with free drainage will hasten recovery. 1 

OSTEOMYELITIS. 

Osteomyelitis of the Hand.— This affection occurs usually as a com- 
plication of neglected cases of cellulitis. The pus, which is not per- 
mitted to escape because of the thick skin of the fingers and hand, 
burrows downward to the region of the bone. As a result the bone, 
surrounded by pus, soon dies and must be discharged before healing 




Fig. 216. — Carbolic gangrene of the finger, 1 per cent carbolic acid solution used dur- 
ing night as wet dressing; loss of tissue in the middle finger includes tendons joints and 
bone. 

can take place. Ordinarily a single phalanx is involved. Primary 
osteomyelitis is a rather rare condition but it may occur in the hand 
in the same manner as elsewhere in the body. Severe, throbbing pain, 
worse at night, associated with tenderness of bone with only slight 
swelling, is characteristic of primary infection. In secondary osteo- 
myelitis, the inflammatory symptoms referable to the bone are obscured 
by the symptoms of cellulitis, and the condition may not be suspected 
until the wound fails to heal and roentgenographic examination shows 
the involvement of the periosteum or bone. 

Treatment.— Primary osteomyelitis should be treated by early in- 
cision and drainage, just as osteomyelitis occurring elsewhere. In 
secondary cases, the process should usually be treated expectantly, 
until the cellulitis has subsided and the bone separated. The per- 
sistent sinus may then be enlarged and the sequestrum removed. 

1 Willems' treatment of infectious arthritis has already been referred to. It has given 
excellent results in gunshot injuries of the joints. Its value in civilian surgery is not 
yet thoroughly established. 



CELLULITIS OF THE END OF THE FINGERS 



321 



In early cases, if involvement of the bone is suspected, free incision 
may be made to the bone in one or two places. When the periosteum 
is reached, it should be incised longitudinally. This will ordinarily 
suffice, for as a rule the pus is located between the periosteum and the 
bone. Occasionally osteotomy is required. The accompanying cel- 
lulitis should receive appropriate treatment. 

SPECIAL INFECTIONS OF THE UPPER EXTREMITY. 

Cellulitis of the End of the Fingers (Felon).— Cellulitis in this loca- 
tion often follows small puncture wounds. There is intense pain and 
tenderness with usually no other evidence of pus formation. The pain, 
which is severe and throbbing in character, is made worse by pressure 
or by warmth. When the hand is allowed to hang down, the con- 
gestion is increased and the throbbing becomes more intense. In 




Fig. 217. — Acute infection of the thumb. Pus cavity on palmar surface. 

cases which are neglected, the swelling gradually becomes more marked 
and the end of the finger becomes dark red in color. Because of the 
thickness of the skin, the infection tends to spread rapidly up the 
finger, but it may remain localized. Frequently the process is confined 
to the end of the finger, pointing after a few days, and healing spon- 
taneously after several months or longer. In such cases the terminal 
phalanx is almost always involved in the inflammatory process, and 
consequently, when spontaneous healing occurs, it is usually with the 
loss of the tip of the finger. 

Treatment.— Severe pain in the end of the finger following a puncture 
wound is always an indication for incision. Never wait for the abscess 
to point. In recent cases of mild degree, a small incision may be made 
at the point of greatest tenderness, care being taken to open the entire 
abscess-cavity and to allow free drainage. In severe cases the entire 
pulp of the finger is infiltrated with pus. The incision in such cases is 
best made by transfixing the finger with a sharp, pointed knife about 
21 



322 



ACUTE INFECTIONS OF THE UPPER EXTREMITY 



one-half inch from the tip, and then dividing the pulp of the finger 
from this point to the tip in a plane parallel to the palmar surface of the 




Fig. 218. — "Collar- button" abscess of the anterior closed space. The pus blister 
may be large and the deep abscess small, as in this diagram, or vice versa. There may 
be more than one sinus between the blister and abscess. A, deep abscess; B, sinus; 
C, pus blister; D, so-called "roof" of the pus blister. (Biewer.) 

fingers. This gives free drainage, and the resulting scar does not 
interfere with the tactile sensations of the finger tip. The wound may 




Fig. 219. — Diagrammatic drawing to illustrate a severer type of eponychia. In this 
instance the infection has spread to the subungual space either proximal to the matrix 
or along its side, or directly through it. 

The nail has become separated from its matrix epithelium, and now forms the roof 
of a pus blister. It has lost its nutrition and acts as a foreign body in an abscess-cavity. 
All the nail that has separated must be removed before healing will take place. The 
arbitrary point where the transition occurs between grossly dense nail and delicate 
stratum lucidum of the epithelium is indicated. This, and not the theoretically proximal 
extremity of the nail in the re-entrant angle made by the matrix and the reflected epithe- 
lium of the eponychium, is the proximal free edge of the nail when it separates. Acute 
flexion of the phalanx often displaces this free edge dorsal to the eponychium, facili- 
tating removal without incision. A, subungual abscess; B, eponychia; C, proximal 
free margin of nail after separation. (Brewer.) 



conveniently be kept open by inserting a piece of rubber tissue into the 
deep angle of the wound in such a manner that the ends of the folded 



CELLULITIS IN THE INTERDIGITAL WEB 



323 



drain extend laterally on each side of the finger. A strip of gauze 
well smeared with boric acid ointment may be used in the same manner. 

Paronychia.— This affection usually follows a "hang nail" or any 
small wound of the cuticle. In early cases there is usually a small 
abscess located beneath the cuticle and superficial to the matrix. 
Later, the pus extends and may pass over the lateral margin of the nail 
and spread beneath the matrix. In severe cases the entire nail may be 
surrounded by pus. 

Treatment.— In very early cases, a small incision in the skin near the 
cuticle may allow for drainage. Usually, however, it is better to open 
along the lateral margin of the nail, so as to allow for drainage from 
beneath it. In many cases the extension is slight and healing will 
occur without injury to the nail. If the spread of pus is more extensive 
and the bed of the nail is involved, the pus will be found beneath the 




Fig. 220. — Cellulitis of the thumbs from biting the nails. 

base of the nail which is raised from its bed and separated from the 
matrix. In such cases, the point of a pair of sharp scissors may be 
inserted under the loose portion of the nail, which may be cut away 
over the entire extent of separation. It is not necessary to cut away 
the portion of the nail which is firmly adherent, as this only opens up 
new channels for infection and serves no useful purpose. After the 
acute inflammation has subsided, it may be desirable to remove the 
remnant of the nail in order to prevent deformity of the new nail, 
which is always perfect if no incision of the matrix has been made. 
Cases of paronychia show unusually slow progress, usually requiring 
six weeks or longer before healing is complete. 

Cellulitis in the Interdigital Web.— Infection of the web of the 
fingers is likely to spread backward into the loose tissues between the 
heads of the metacarpal bones, and then along the tendons of the 
short muscles into the palm of the hand. Infection of the web between 



324 ACUTE INFECTIONS OF THE UPPER EXTREMITY 

the thumb and the index finger is very common and likely to be trouble- 
some, owing to the fact that extension takes place through the numerous 
tissue spaces between the small muscles of the thumb and index finger. 
Swelling occurs early and is much more evident than in cellulitis of the 
palm. 

Treatment.— Early and complete division of the entire finger web is 
indicated in most cases. It is a good plan to bandage the fingers 
widely abducted, because adduction of the fingers tends to close the 
incision and prevent drainage. 











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Fig. 221. — Chronic infection of hair follicles on back of the proximal phalanges. 

Infection of Hair Follicles.— Very frequently a hair follicle on the 
back of the fingers or hand becomes infected. The mouth of the 
follicle is swollen and reddened and there is early formation of a small 




Fig. 222.— Infection of hair follicle on the back of the finger, one month's duration, 
resulting in necrosis of the extensor tendon. Not incised. Tendon still sloughing. 

pustule. At the same time the infection spreads downward through 
the canal to the hair gland, which becomes distended with pus. When 
fully developed there is a papular swelling, at the apex of which is a 



CELLULITIS OF THE FOREARM 



325 



yellow pustule. There is usually a secondary abscess-cavity beneath 
the skin, larger than the superficial pustule and connected with it by 
a narrow canal. This is the so-called " collar-button abscess/' the 
superficial pustule representing the head, the abscess of the hair 
follicle the base, and the hair canal the shank of the button. In the 
treatment of this affection it should be remembered that the deep 
abscess lies beneath the skin and the incision should be deepened down 
to this point. The mistake is often made of incising only the superficial 
pustule, without recognizing the fact that the deep abscess exists. 




Fig. 223. — Infection, following bite on the 'arm and showing little tendency to heal. 

Duration, two weeks. Non-specific. 

Cellulitis of the Forearm.— The general principles in the treatment 
of cellulitis of the forearm are the same as the treatment of cellulitis 
elsewhere. The infection may spread to the forearm from the hand, 
or it may begin as an infected wound, usually about the wrist. Owing 
to the fact that the pus tends to spread between the muscular planes, 
there is little tendency to localization and abscess formation. Pain and 
swelling may be the only symptoms. 




Fig. 224. — Acute pustular dermatitis. Result of putting the wet bichloride dressing on 
the arm previously painted with iodine. 



Treatment.— Longitudinal incisions should be made, as soon as the 
diagnosis is clear, down to and through the muscles. In order to avoid 



326 



ACUTE INFECTIONS OF THE UPPER EXTREMITY 



injury to the vessels and nerves, the deep tissues should be separated 
by blunt dissection. It is often advisable to search out all the small 
cavities with the finger during the course of the operation. Through- 
and-through drainage may be instituted, a soft rubber tube of fairly 
large caliber being the best form of drainage material. The after- 
treatment is the same as for cellulitis of the hand. 

Supracondylar Abscess.— This is actually suppurative lymphadenitis 
of the supracondylar lymph gland. It may occur as a result of an 
infected wound of the hand, but in some cases the point of infection 
in the hand may have been healed for days or weeks before the gland 
suppurates. 

Treatment.— In the case of a subacute swelling of this gland, it is 
permissable to wait until the gland has had time to break down; but 
if the gland is rapidly growing larger and the area of induration is 
increasing, it is better policy to incise at once. The after-treatment is 
the same as for cellulitis. Healing is likely to be delayed. 




Fig. 225. — Chronic axillary adenitis in woman, aged twenty-eight years, never clear for 
more than two weeks at a time. Duration, several years. 



Abscess of the Axilla.— Abscess of the axilla occurs frequently in 
cases of acne, furunculosis, etc., and it may also start as a skin irrita- 
tion, the result of maceration and chafing due to tight clothing and 
dress-shields. A commoner cause of late is the practice of depilation of 
the axilla, either by shaving or by the application of a hair-remover, 
in which case the hair is either cut or burned off below the surface of 
the skin resulting in infected ingrowing hairs. 

Owing to the loose tissue filling the axilla, all infections of the skin 
in this region have a tendency to burrow internally instead of dis- 
charging externally; so that while the superficial lesion may be small, 
a large pocket of pus may form deep in the axilla. The abscess may, 
however, start from the breaking down of the axillary lymph nodes, 
which receive their infection from the lymphatic channels draining 
the neck, chest, arm and hand. It is common in infections of these 



ABSCESS OF THE AXILLA 327 

areas to have enlargement of the axillary lymph nodes. This enlarge- 
ment usually subsides when the initial lesion is properly treated. 

Treatment.— In opening the abscess the hair of the axilla should be 
clipped and not shaved. If the abscess points, incision should be made 
over the point of fluctuation ; but when, as so often happens, drainage 
of the abscess must be made through uninvolved tissue, the skin should 
be incised over the dependent part, and the abscess approached by the 
blunt method, thus avoiding injury to the important structures that 
pass through the axilla. As the drainage tract passes through normal 
tissue having an abundant blood supply, unless a drain is kept well 
inserted, the incision will heal rapidly and the abscess will reform. 

It is common to see axillary abscesses that have recurred many times. 

In applying the gauze dressing to the axilla, care must be taken to 
support the drain, otherwise the movements of the arm will gradually 
work it out. 



CHAPTER XL 
MISCELLANEOUS AFFECTIONS OF THE HAND AND ARM. 

BURSITIS. 

Any of the bursas about the upper extremity may be the seat of 
acute or chronic inflammation. While the location of larger bursas 
is well known and consequently affections of these bursas are readily 
recognized, mistakes in diagnosis are very common in the case of 
smaller bursas such as, for example, the small bursse beneath the 
insertion of the flexor carpi radialis. Enlargement of this bursa is 
common in carpenters and after Colles' fracture is frequently 
overlooked. 

Subdeltoid Bursitis.— A large bursa is situated over the shoulder- 
joint and beneath the acromion and deltoid muscle. Inflammation 
of this bursa is known as subdeltoid or subacromial bursitis. The 
acute variety may be caused by a blow or it may follow a sprain or dis- 
location of the joint. It is quite frequently seen after exercise involving 
violent use of the shoulder, such as golf or tennis. This condition is 
frequently seen in commuters and is apparently due to resting the 
shoulder against the cold window panes in over-heated cars. It is 
also seen in explorers and others who sleep with insufficient bedding on 
cold ground or ice. 

Because of the unyielding character of the surrounding structures, 
pain in the region of the shoulder is most acute. It extends down the 
arm and is associated with more or less spasm of the muscles. There 
is pain on abducting the arm and tenderness over the point of the 
shoulder. If this tenderness is carefully mapped out it will be found to 
coincide exactly with the subdeltoid bursa. When the arm is abducted 
the bursa slips back beneath the acromion so that the area of tenderness 
may be diminished or absent in this position. On account of the 
thickness of the deltoid muscle it is difficult to demonstrate swelling 
in the milder cases. 

According to Codman there is a subacute type of bursitis in which 
there are adhesions between the floor and roof of the bursa which 
cause mechanical interference with movements of the joint. Pain, 
stiffness, and weakness of the arm are prominent symptoms. 

In the chronic form of subdeltoid bursitis, the bursa is thickened 
and irregular and may show calcareous deposits. The movements 
of the arm show very little limitation and pain is not likely to be severe. 
The patient usually suffers from frequent acute or subacute attacks of 



BURSITIS 329 

pain in the shoulder, which may subside entirely between attacks, 
or persist as an acute, stabbing pain whenever the shoulder is actively 
moved in certain directions. Some patients complain of pain on draw- 
ing on an overcoat, and others say that attempts to throw a stone or 
other small object causes a sharp pain in the region of the deltoid 
muscle. 

Bursitis occurring in any of the above forms may become infected, 
causing a marked increase of the local symptoms associated with fever 
and toxemia. Rheumatism of the bursa has been reported, but it is 
uncommon except when associated with acute rheumatic fever and 
infection of other joints. 

Treatment.— For the acute variety rest, with the arm abducted, 
is most important. This may be secured by the use of a splint, or by 
allowing the arm to rest on a pillow placed on a table beside the 
patient during the day, and in a position so that the arm is held in 
partial abduction in bed at night. This relaxes the deltoid and 
enlarges the cavity of the bursa. Care should be taken not to have the 
arm overabducted or the shoulder held in a strained position, or the 
pain will be made worse. It is usually wiser to allow the patient to 
adjust the arm to the exact degree of abduction which is most com- 
fortable. 

After the acute pain decreases, the arm may be carried in a sling for 
a day or two. In most acute cases the condition subsides rapidly. 
It is not unusual to see a patient, who, following active exercise, 
suffers pain severe enough to keep him awake all night, recover so 
rapidly that in forty-eight hours he feels entirely well. Such cases 
on examination still show tenderness, but have little or no pain in 
ordinary movements of the joint. With the relief of pain there often 
appears a more prominent swelling over the region of the bursa, and 
occasionally a straw-colored or hemorrhagic fluid may be withdrawn 
with an aspirating needle. The sudden cessation of pain is probably 
due to the floating apart of the inflamed surfaces, and is analagous to 
the cessation of pleuritic pain when effusion occurs. During this stage 
the shoulder may be strapped and the patient allowed to use the arm 
freely for light work, care being taken to avoid overuse of the shoulder, 
which will cause recurrence. Golf, tennis, or heavy muscular labor 
may be resumed after about two weeks. 

In the subacute cases with adhesions, the joint should be forcibly 
abducted, under an anesthetic if necessary, in order to break up the 
adhesions. Massage, baking, and active and passive movements of 
the joint are advised. If the condition persists, incision with division 
of the adhesions may give relief. 

In the chronic cases with thickening of the bursa and calcareous 
changes, partial or complete excision of the bursa may be required. 

If the bursa becomes infected as shown by increased tenderness and 
swelling and more or less well-marked general symptoms, it should be 
aspirated with a large aspirating needle. The cavity should be 



330 MISCELLANEOUS AFFECTIONS OF THE HAND AND ARM 




irrigated with saline and treatment continued as in the acute cases. 1 
If this does not relieve the symptoms, the sac should be incised, 
swabbed with pure carbolic acid, and dressed with an antiseptic wet 

dressing. If the first incision is made 
large enough, it will be found un- 
necessary to use a rubber tube to 
secure drainage of the bursa. The 
patient should be allowed to use 
the shoulder a little, the movements 
pressing out the discharge, thus keep- 
ing the cavity thoroughly drained. 

Olecranon Bursitis. — This may 
arise as a consequence of injury, or 
it may be the result of chronic 
trauma, such as occurs in miners 
who are obliged to lean on the elbow 
when at work (miner's elbow). The 
diagnosis is evident from inspection, 
the bursa being located over the 
olecranon and just beneath the skin. 
The swelling is circular in outline 
and somewhat resembles the shape 
of half an orange. In the acute 
cases, the pain is severe and made 
worse by extreme flexion of the elbow. In the chronic cases, there 
is little or no pain except on pressure. In septic cases, such as 
are seen following wounds of the bursa, there is comparatively little 
swelling, the serous exudate being dis- 
charged through the wound. In the sim- 
ple cases, the bursa contains clear serum, 
but owing to the exposed position of the 
swelling, infection through an abrasion of 
the skin or through an infected hair 
follicle is fairly common. If this hap- 
pens, the bursa becomes more painful, 
the skin over the swelling becomes red- 
dened, indurated, and more or less firmly 
attached to the underlying bursa, and 
there are liable to be fever and other 
general symptoms of infection. 

Treatment.— Acute bursitis due to trau- 
ma will Usually subside in from one to two . FlG - 22 7 -Olecranon bursitis, 
,.„. ~ .pi !• i two months duration; no acute 

weeks it the elbow is nrmly strapped in such trauma. (Ashhurst.) 



Fig. 226. — Chronic suppurative 
bursitis of the elbow, with draining 
sinus. Duration, over one year. 




1 Excellent results have been obtained by aspiration of the sac with injection of 
Murphy's solution (2 per cent formalin in glycerin). About 2 to 4 cc may be injected 
through the aspirating needle. We have found that the addition of 1 per cent quinine 
and urea to the solution tends to relieve pain. 



BURSITIS 



331 



a manner as to cause pressure on the bursa. During the later stages after 
the strapping is removed the use of iodine or other form of counter- 
irritation may be of value. If there is suppuration, the sac may be 
incised and packed with iodoform gauze, or left open and treated with 
antiseptics until the discharge is sterile, and then closed by secondary 
suture. Wounds of the bursa heal very slowly, because the serous 
exudate is an excellent culture medium and tends to encourage infec- 
tion. In old cases, where there is a discharging sinus with thickening 
of the sac, the attempt may be made to cause obliteration of the sac 
by swabbing the walls with pure carbolic acid and then applying 
pressure to approximate the walls of the cavity. If this is unsuccessful, 
it is necessary to excise the entire thickened sac. 




Fig. 228. — Granuloma of the elbow, following incision for three weeks before for infec- 
tion of the olecranon bursa. 



In chronic cases, due to continued irritation, the effusion may subside 
under strapping so applied as to cause pressure on the sac. Aspiration 
of the sac with the withdrawal of the fluid, repeated at intervals of 
two or three weeks, will usually cause a gradual subsidence of the 
process if the cause is removed. In obstinate cases, carbolic acid may 
be injected in the attempt to obliterate the sac, in the same manner as 
in the treatment of hydrocele of the tunica vaginalis. Where the walls 
are thickened, excision of the entire sac may be indicated. In any case, 
it is advisable to warn the patient that the continued trauma of the 
elbow must be discontinued. In cases cured by conservative treat- 
ment, the return to work, requiring trauma to the elbow, will result in 
recurrence. After radical extirpation of the sac, the natural protective 
action of the bursa is absent, and long-continued irritation over the 
olecranon is likely to result in chronic ulceration. 



332 MISCELLANEOUS AFFECTIONS OF THE HAND AND ARM 

When secondary infection occurs in the course of an acute or chronic 
bursitis, aspiration and the injection of Murphy's solution should be 
tried. If this is successful a large incision should be made so as to 
afford free drainage. Antiseptic dressings should be applied, and the 
condition treated as an abscess. The insertion of a rubber tube for 
drainage is not advised. If healing is delayed, the serous lining of the 
bursa may be cauterized with pure carbolic acid or silver nitrate. 
Occasionally a case occurs in which the incision heals, and the bursa, 
after a period of indolent inflammation, gradually returns to normal. 
More frequently a troublesome sinus persists for several weeks or 
months. If, after prolonged treatment, the sinus continues to dis- 
charge, the bursa should be removed by operation. 

ARTHRITIS. 

Arthritis of the Fingers.— The joints of the fingers and hands are 
frequently the seat of acute and chronic arthritis. Occasionally the 
joints of the wrist or fingers may be affected as one of the early symp- 
toms of acute articular rheumatism. Swelling of the interphalangeal 
joints has long been recognized as one of the early symptoms of rheu- 
matoid arthritis. It is commonly believed now that most of these 
chronic joint affections are the result of infection, the focus of which 
is often located in the tonsils or about the roots of the teeth. Acute 
suppurative arthritis may follow wounds in the region of the joint. 
It is less common than might be anticipated from the large number of 
infected wounds which occur upon the fingers and hands in close 
proximity to the joint. 

Treatment.— Treatment should be directed toward the removal of 
the focus of infection, wherever located. The local treatment consists 
principally in local applications of heat and the use of a splint to secure 
rest for the affected joints. The underlying condition should receive 
appropriate treatment. Suppurative arthritis occurring about the 
hands should receive the same treatment as similar arthritis occurring 
in a large joint. 

Gonorrheal Arthritis.— While articular rheumatism and other types 
of infectious arthritis are usually sent to the physician, gonorrheal 
arthritis frequently comes under the care of the surgeon. This is 
because the local infection of the urethra is considered surgical in 
character, and because of the fact that the arthritis ordinarily is non- 
articular resembling simple suppurative arthritis. The wrist is 
involved in about 15 per cent of all cases of gonorrheal arthritis. 

The swelling is characteristic, involving both the joint and the 
periarticular structures, so that in the wrist, a fusiform swelling results. 
There is acute pain on movement of the affected joint, but less than in 
acute articular rheumatism. On the other hand, while the joint has 
somewhat the appearance of tuberculosis, there is considerably more 
pain than in the latter condition. The diagnosis rests upon the acute 



ARTHRITIS 333 

onset during the course of an acute or chronic urethritis, associated 
with the characteristic swelling. There may be a slight fever, but the 
general symptoms are 'ordinarily not marked. The disease is of long 
duration, lasting for weeks or months. 




Fig. 229. — Acute gonorrheal arthritis of the wrist, following acute urethritis. Dura- 
tion one week. 

Treatment.— During the acute stages, the joint should be put at rest 
and all local treatment of the urethra discontinued. Rest in bed is 
advisable during the early stage. If the wrist is involved, it should be 
well wrapped in cotton, and a posterior splint applied from the elbow 
to the tips of the fingers. Local applications of methyl salicylate, or 
guaiacol (20 per cent) in glycerin, seem to have some influence on the 
acute pain. In the later stages, baking with dry heat or electric light 
baths is beneficial, and after the acute inflammation has subsided, 
careful exercise and massage aid the return of function. 










Fig. 230.— Old untreated case of gonorrheal arthritis, with complete immobility of 

wrists. 

The use of vaccines is especially indicated in gonorrheal arthritis. 
It has been our custom to begin with small doses, 25 million gonococci, 
gradually increasing the dose at five or six day intervals to 200 million. 



334 MISCELLANEOUS AFFECTIONS OF THE HAND AND ARM 

Larger doses are rarely given. The results following this method of 
treatment are occasionally most striking. A few cases are not affected. 

Gouty Deposit.— Gouty deposit may be found in any part of the 
body, but is especially common around the small joints of the fingers 
and toes and the inner cartilage of the ear (tophi) . 

This deposit consists of sodium urate, and where extensive forms, 
the chalky deposit of the older writers. Trauma is often the determin- 
ing factor in locating these deposits, as in the gouty bursa of the knees 
and elbows. 

Treatment.— Gouty deposits may be curetted or, like other foreign 
bodies, excised. They are liable to recur and may need repeated 
removal. When the capsule of a joint is involved, care must be taken 
to avoid opening the joint. 




Fig. 231. — Tuberculosis of the wrist in a shoemaker. Would not stop work or use 

splint. Duration, three years. 



TUBERCULOSIS OF THE ARM AND HAND. 

Tuberculous Arthritis.— All forms of surgical tuberculosis are found 
in the hand and arm. Tuberculosis of the elbow and wrist-joints 
occurs fairly frequently. The disease usually begins in the synovial 
membrane and extends later to the adjoining bone. The early symp- 
toms are limited to slight pain and partial loss of function. As the 
disease progresses, the joint becomes swollen and tender. Early 
atrophy of the muscles about the joint is the rule. Roentgenographic 
examination shows the involvement of the bone, except in early cases. 
When tuberculosis involves the hand, it is seen most frequently in the 
small bones of the fingers, resulting in a fusiform swelling of the finger. 
Involvement of the interphalangeal joints occurs less commonly, 



TUBERCULOSIS OF THE ARM AND HAND 



335 



Treatment.— Fixation for long periods is the approved method of 
treating tuberculosis of the joints. A plaster cast is applied in such a 
manner as to keep the joint completely at rest, and this treatment is 
continued for six months or longer. For advanced cases, and cases of 
tuberculous osteomyelitis showing a distinct sequestrum in the roent- 
genograph, operation with complete removal of the focus of disease is 
the best plan of treatment. In tuberculosis with sinus formation, where 
the complete removal of the disease is difficult or impossible, satis- 
factory results have been obtained with tuberculin. It should be 
emphasized that in all cases of tuberculosis, even when the focus of 
disease is apparently most insignificant the constitutional and hygienic 
treatment must be carefully 
carried out. Heliotherapy has 
given excellent results in these 
cases. 

Tuberculosis of the Tendon 
Sheaths.— Tuberculosis of the 
tendon sheaths about the wrist 
is of fairly common occurrence. 
It is most frequently seen on 
the palmar aspect of the forearm 
and hand, but may occur along 
the extensor tendons. It begins 
with slight distention of the 
sheath with serum which may 
contain rice bodies. The swell- 
ing is elongated in shape and is 
constricted at the annular liga- 
ment, forming an hour-glass 
swelling. It is ordinarily pain- 
less, or nearly so. Pressure 
on the swelling in the palm 
causes it to diminish in size, with a corresponding increase in the size 
of the swelling in the forearm. There may be a sensation of rough 
crepitus, or grating, on movement. In the early stages, the mass is 
fluctuating in character, but later, when fibrous changes become more 
marked and the sheaths become thickened, the swelling becomes 
firmer. Caseation and abscess-formation may occur. The course of 
the disease is very slow, many cases showing a duration of several years 
with slight or no discomfort. 

Treatment.— In the early stages before extensive granulation has 
occurred, a small incision should be made through the sac wall and the 
contents of the tendon sheath expressed by gentle pressure. The sac 
should then be injected with iodoform emulsion or formalin-glycerin, 
and the wound closed. The wrist is fixed with a light posterior splint, 
which is left in place for three weeks or longer. In a considerable 
number of cases this will result in cure, Recurrence is not uncommon, 




Fig. 232. — Tubercular adenitis of the 
axilla in a man, aged forty-five years. Dura- 
tion, two years. 



336 MISCELLANEOUS AFFECTIONS OF THE HAND AND ARM 

and in some cases it may be necessary to repeat this operation at 
intervals of several months. Where there are extensive tuberculous 
charges with thickening of the tendon sheath, a large incision should 
be made and the entire diseased area dissected away. If necessary, 
the annular ligament must be cut and the palmar fascia divided. 
Extreme care is required to prevent injury of important vessels and 
nerves. All granulation tissue around the sheath and attached to the 
tendon must be removed, including lateral prolongations of the process, 
should these occur. 1 The wound may be swabbed with formalin- 
glycerin at the end of the dissection. The annular ligament is then 
repaired, the skin carefully sutured, and the hand placed upon a splint 
until healing is complete. 

The non-operative treatment, which may be used alone or combined 
with operation, consists of the use of the Bier hyperemia method, 
tuberculin in very small doses, and adequate attention to the general 
health. The roentgen ray has been advised and favorable results have 
been reported. We have seen its use followed by especially favorable 
results in cases where there have been secondary infection and suppura- 
tion. 

Non-tuberculous Tenosynovitis.— Non-tuberculous tenosynovitis of 
a chronic type may occur. The clinical appearance is similar to the 
early stages of the tuberculous variety. There is little or no pain or 
tenderness, as a rule. The patient complains of stiffness and swelling 
and a sensation of crepitation on motion. It may result from repeated 
attacks of the acute variety or it may be due to rheumatism, gout, 
rheumatoid arthritis, or gummatous infiltration. 

Treatment. —The treatment depends on the cause. Rest, baking, and 
hyperemia may have a favorable influence when the condition is trau- 
matic in origin. 

Tuberculosis of the Phalanges (Spina Ventosa).— A spindle-shaped 
swelling of one of the phalanges due to tuberculosis of the shaft of the 
phalanx is called spina ventosa (tuberculous dactylitis) and is fre- 
quently seen in children. It is no different from tuberculosis of the 
shaft of any bone, but the bone changes are particularly evident because 
of the superficial location of the phalanges. The swelling is only 
slightly painful, but the child holds the finger stiff and is likely to cry 
when the finger is roughly handled. As a rule the joints are not 
involved. There is frequently a history of trauma. 

The condition is due to the death of bone with the formation of a 
sequestrum followed by the growth of the involucrum around the dead 
bone. Roentgenographs are of value in demonstrating the extent of 
the process and the character of the sequestrum. If untreated, the 

1 It should be remembered that excision of the tendon sheath as outlined above is a 
long tedious operation and requires an intimate knowledge of the structures about the 
wrist. Moreover it may easily require three hours or even longer. As an operation of 
this length is not without danger to a subject with tuberculosis, the operation should be 
performed under local anesthesia with blocking of the larger nerve trunks supplying the 
region of the wrist. 



TUBERCULOSIS OF THE ARM AND HAND 



337 



swelling increases and may involve the joint, or it may break down and 
discharge externally. A spontaneous cure may occur. 

Syphilis may cause a condition which exactly simulates tuberculosis 
of the phalanx. The disease usually occurs in children as a mani- 




Fig. 233. — Multiple tuberculous lesions of the small bones of the hands; child otherwise 
healthy. Duration of disease two years. 

festation of hereditary syphilis, and is likely to be accompanied by other 
syphilitic changes. Due to the weakness of the phalanx, pathological 
fracture may occur. 




Fig. 234. — Roentgenograph of tuberculous involvement of the small bones of the hands. 

Treatment.— Tuberculosis of the phalanx may be cured in the early 

stages by conservative treatment, as outlined under the treatment 

of tenosynovitis. If the disease has reached an advanced stage, the 

necrotic bone should be removed by operation, An incision is made 

22 



338 MISCELLANEOUS AFFECTIONS OF THE HAND AND ARM 

down to the bone on the lateral aspect of the finger, and the involucrum 
is opened with a chisel or gouge. Often it is so thin that it may be 
broken through with the blunt end of an artery-clamp. The cavity is 
scraped with a small curette so as to remove all dead bone, and the 
interior swabbed with pure carbolic acid and followed by alcohol. 
Iodoform gauze is packed in the cavity and the wound is allowed to 
heal by granulation. In favorable cases, if it is reasonably certain 
that all the diseased bone has been removed, the cavity may be filled 
with bismuth paste and the incision sutured without drainage. This 
will sometimes result in cure. The finger should be placed at rest by 
the use of a splint or other form of apparatus. Measures for the 
improvement of the general health should not be neglected. The 
carefully controlled use of the roentgen ray is frequently followed by 
excellent results. 

SYPHILIS OF THE HAND AND ARM. 

Syphilitic infection of the arm and hand is of fairly frequent occur- 
rence. The lesions of every stage of syphilis may be found in the hand 
from the primary sore, the result of direct infection, to the gummata 
of the tertiary stage. Chancres are occasionally the result of injuries 
to the knuckles caused by striking a blow against the teeth of a syphi- 




Fig. 235. — Syphilitic involvement of the finger in a young negress. Painless. 



litic patient. In doctors and nurses the primary lesion is occasionally 
the result of a slight scratch or abrasion received with a dirty instru- 
ment. 

In secondary syphilis, the enlargement of the epitrochlear lymph 
node is the most common symptom. In tertiary syphilis, eczema of the 
palm, gummata, and syphilitic dactylitis are the commonest types of 
the disease. 



SYPHILIS OF THE HAND AND ARM 



339 



Syphilitic Dactylitis.— Syphilitic dactylitis which is either a syphilitic 
arthritis or osteomyelitis of the fingers, is fairly common and of especial 
importance because it resembles tuberculosis. It results in a fusiform 




Fig. 236. — Syphilis of the arm, following horse bite. 

swelling which is almost identical with the swelling resulting from 
tuberculosis of the phalanx. If the patient has not been taking- 
treatment, a negative Wassermann reaction almost certainly excludes 
syphilis. 




Fig. 237. — Charcot's joint of the elbow. 

Treatment.— Surgical procedures are rarely indicated in uncom- 
plicated syphilis. Excellent functional results usually follow the rou- 
tine syphilitic remedies. It is remarkable what good results are 
obtained in cases showing marked syphilitic changes. 



CHAPTER XII. 
TUMORS AND DEFORMITIES OF THE ARM AND HAND. 

BENIGN TUMORS OF THE ARM AND HAND. 

There is a group of tumors of the upper extremity composed of 
fibrous, fatty, and nerve tissue in varying proportions. Where the 
nerve element predominates, they are known as neuromata; where 
the fibrous predominates, they are known as fibromata. 

Between these two is a group of tumors classified as neurofibromata 
and fibroneuromata, according to the predominance of nerve or fibrous 
element. The neurofibromata, owing to the greater quantity of nerve 
element present, are more sensitive than the fibroneuromata. 

Neuroma.— Pure neuromata are rare and usually small. They may 
occur wherever there are nerve filaments. 

Neurofibroma.— Wherever a nerve-trunk is cut across or lacerated 
the proximal filaments continue to grow, and if unable to reach the 
distal sheath, as in amputation, they pile up, forming a gnarled mass, 
which contains a varying amount of fibrous tissue. These masses may 
be as small as the beadlike outgrowths along the nerve trunk; or they 
may be as large as a lemon, as seen in amputation stumps. 

Fibroma. — This is a benign growth of rather frequent occurrence, 
especially about the hand. It is often in, or closely attached to, the 
skin; but it may occur on the tendons or tendon sheaths. The tumor 
is of slow growth and is usually painless. It may be hard and firm, 
or it may contain fat (fibrolipoma), in which case it is soft and flabby. 
The small, firm growths greatly resemble sarcomata. Indeed, the 
resemblance is so marked that when a tumor has been removed, it is 
usually necessary to wait for the microscopic examination in order to 
be certain of the diagnosis. 

Treatment.— Should the tumor suggest sarcoma, it should be removed 
by wide excision and sent to a competent pathologist for examination 
and report. Frozen sections of these small tumors are unsatisfactory. 

The question of a secondary operation in cases in which the report 
is "sarcoma" has not been definitely decided. It has been advised 
that in these cases the wound should be opened and the surrounding 
tissue removed for a considerable distance. This procedure we have 
considered unnecessary. At the operation, the possibility of sarco- 
matous change is borne in mind, and the tumor, together with the 
surrounding tissue, removed to an extent sufficient to make certain 
that the entire tumor has been removed. Experience has shown that 
|hese srnajlj chronic growths, even when reported sarcomatous rarely 



BENIGN TUMORS OF THE ARM AND HAND 



341 



recur. If, after removal, there are signs of recurrence in the scar, the 
scar and a considerable area of the surrounding tissue should be 
removed. 




Fig. 238. — Fibroma of the finger. Duration, several years. 

Lipoma.— Lipomata of the upper extremity are similar to lipomata 
in other parts of the body, except for the fact that as a rule they contain 
more fibrous and nerve element, are therefore firmer and more sensitive, 
and rarely grow as large. 





Fig. 239. — Diffused lipoma of the 
palm in a woman, aged thirty-five years. 
Noticed for three years. 



Fig. 240.— Large lipoma of the arm. 
Slow growth. 



On the other hand, in the axilla we may find pure lipomata so softly 
elastic that they appear cystic. These axillary lipomata may attain 
a large size and interfere with the adduction of the arm; or they may 
early press upon nerves and bloodvessels, giving characteristic symp- 
toms. 



342 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

In diagnosing axillary lipomata, one should keep in mind the rarer 
tumors that may be found in this region, such as hygromata, aberrant 
mammary glands with or without nipples, and aneurysms. 




Fig. 241. — Lipoma of the axilla. 



Treatment.— Due to the fact that the arm is used so extensively, 
early excision of lipomata in this region is indicated. In excising the 
growth, the close proximity of important structures must be kept in 
mind. 




Fig. 242. 



-Large axillary hygroma present since birth. No inconvenience except for 
the size of the armhole required in the coat. 



Hygroma.— Hygromata of the axilla are usually secondary to 
hygromata of the neck, the growth extending down along the vessels 



BENIGN TUMORS OF THE ARM AND HAND 



343 



and nerves and invading the loose tissue of the axilla where they may 
grow to a large size. 

Treatment.— See treatment for Hygromata of Neck. 

Sebaceous Cyst.— Sebaceous cysts occasionally occur upon the arm 
or hand. They are much less common in this location than on the 
head and back. When present, they require removal, as has been 
outlined elsewhere. 

Papilloma.— Papillomata, or warts, are of frequent occurrence, 
usually being located upon the wrists or hands. They are much more 
common during childhood than during adult life, but they may occur 
at any age. The fact that they usually occur on the exposed surfaces 
of the hands or face would lend weight to the theory that they are the 
result of local irritation. Indeed, in many cases there is a distinct 
history of a slight injury, such 
as a neglected splinter or abra- 
sion, before the wart is noticed. 

They are found in two forms : 
a smooth, sessile growth only 
slightly elevated above the skin; 
and a rough cauliflower growth 
which may be elevated one- 
eighth of an inch or more. In 
most cases they occur as iso- 
lated growths rarely more than 
one-fourth of an inch in dia- 
meter, but they may be larger; 
or several may coalesce form- 
ing a flat, papillomatous tumor 
as large as a quarter. When 
untreated they usually grow 

slowly larger for several months, or longer, tending to become more 
pedunculated. Finally they are torn away by some slight trauma, after 
which they may or may not reappear. The surface is hard and may 
become cracked or fissured, which in turn permits infection of the wart 
and the surrounding tissue. 

Treatment.— In children, warts are likely to disappear spontaneously, 
so that unless they are disfiguring, it is unnecessary to remove them. 
In adults, the growths are more permanent and should be removed. 

The simplest form of treatment is cauterization with strong acid. 
Either nitric or monochloracetic may be used. We have found 
monochloracetic acid more satisfactory. In using this acid, which 
comes in crystalline form, a small crystal is placed upon the wart and 
a drop of water added to dissolve it. After about three to five minutes 
it is washed away to prevent too deep cauterization. The surface of 
the wart becomes dry and pale after a day or two. This cauterized 
tissue should be pared away about the third day, and more acid applied 
to the surface of the wart. Four or five treatments will result in the 
permanent disappearance of the growth. 




Fig. 243. — Wart on the back of the hand. 
Woman, aged fifty-four years. 



344 TUMORS AND DEFORMITIES OF THE ARM AND HAND 



Avulsion will remove some of the larger, more or less pedunculated, 
growths. After injecting 5 per cent novocain about the base of the 
growth, the wart is seized with an artery-clamp and pulled from its 
bed. If successful, the roots will be pulled out with the growth. If 
this does not remove the entire wart, the base may be touched with 
monochloracetic acid or a caustic potash stick. After removing the 
excess of the caustic, a sterile dressing is applied. 

The sessile form may be removed with a sharp curette. Under 
local anesthesia the growth is curetted down to what appears to be 
normal tissue, and the curetted surface cauterized as above. This 
method is applicable to large, flat warts and those occurring on the 
palms of the hands. 

Excision is still better, when the surface covered by the wart is not 
too great. Care must be taken to remove all the deeper parts of the 
wart, but it is unnecessary to remove any of the surrounding skin. 

When there are a large number of warts, favorable results can some- 
times be obtained by frequent applications of a volatile oil, such as 

oil of cinnamon. The surface 
of the growth is painted with 
the oil every night until the 
warts disappear. 

Osteoma. — (Exostosis. 
Bony Spurs).— This is a fairly 
common affection of the hand. 
It is usually present in the 
form of a hard, painless, or 
nearly painless, tumor at- 
tached to the bone. Osteo- 
mata are rather common on 
the phalanges and the meta- 
carpals. They must be differ- 
entiated from sarcoma and 
from syphilis. The diagnosis is made by palpation and confirmed 
by the roentgenograph. Involvement of the entire bone with a 
tendency to cyst formation is indicative of sarcoma. 

Treatment.— The skin is incised over the tumor and the soft parts 
are retracted. In most cases if care is taken to anesthetize carefully 
the tissues surrounding the bone, the operation may be performed 
under local anesthesia. When the bone is exposed, the growth should 
be removed with a chisel or sharp burr. The wound is sutured, and 
the tumor sent for microscopic examination. Should the report show 
sarcoma it is best to remove the entire affected bone. 

Ganglion.— A special type of cystic tumor occurring in the region 
of the wrist is known as a ganglion. It consists of a sac filled with a 
translucent, gelatinous fluid. Ordinarily the sac is intimately con- 
nected with the synovia of the joint or tendon sheath, but the cavity 
of the sac rarely connects with the joint and is not, as formerly believed, 




Fig. 244. — Recurrent granuloma of the finger 
two weeks after removal of splinter. 



BENIGN TUMORS OF THE ARM AND HAND 



345 



a hernia of the synovial membrane of the joint or tentlon sheath. It 
has been accounted for on the theory that it is a true tumor which has 
undergone cystic degeneration. This theory is not definitely proved. 
A ganglion first makes its appearance as a small, round tumor on the 
dorsum of the hand over the wrist-joint and only occasionally in other 
locations. When the joint is hyperextended, the tumor is not readily 
seen ; but when the wrist is sharply flexed, the tumor appears as a tense, 
rounded eminence firmly attached to the deeper parts. The overlying 
skin is freely movable. It is often first noticed after a sprain or some 
unusual exertion of the wrist, and is likely to increase slowly in size. 
A ganglion may disappear spontaneously. Compound ganglion is the 
name given to tuberculous tenosynovitis of the wrist. 

Treatment.— The simplest treatment of ganglion is rupture of the sac. 
This was formerly accomplished by hitting the ganglion a sharp blow 
with a heavy book. This method we condemn, as the blow may injure 
the wrist or fracture some of the small bones ; but as this method pro- 
duced about 40 per cent of cures, rupture of the sac is well worth trying. 




Fig. 245. — Ganglion of the wrist in a school teacher. Painful. Duration, two years. 



In thin-walled ganglion this can be accomplished by flexing the wrist 
so as to make the ganglion more prominent, and pressing upon the sac 
with the thumbs until it ruptures. The contained fluid is then firmly 
massaged into the surrounding tissues. In most cases, the cyst-wall 
is so thick that pressure sufficient to rupture the sac is acutely painful. 
In these cases it has been our practice to give a whiff of. gas, when the 
procedure can be successfully carried out. Should the ganglion recur, 
the above treatment may be repeated, although the chance of cure by 
this method decreases rapidly in recurrent ganglion. 

In selected cases, and especially in those that persistently recur, 
excision of the sac is the method we advise. Under local anesthesia 
a longitudinal incision is made in the skin down to the fibrous capsule. 
This is carefully dissected out by blunt dissection until the deep 
attachment is reached. If the tumor is pedunculated, the pedicle 
may be ligated and the entire growth removed; but if the base is sessile, 
it is advisable to open the cyst and excise the cyst-wall without attempt- 
ing to remove the fibrous capsule at its attachment to the deeper parts. 
If the joint-cavity or the synovial sheath of the tendon is opened, it 



346 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

should be closed ^with fine catgut. The skin is closed with fine silk or 
horsehair sutures. 

Another method which has been advised is the aspiration of the 
contents of the sac with the injection of 5 drops of pure carbolic acid, 
tincture of iodine, formaldehyde, etc. Because of the jelly-like con- 
sistency of the contents, it is necessary to use a comparatively large 
needle for this operation. This method we condemn as the reaction 
may produce permanent functional injury. 

In thick-walled and recurring ganglions, a plan of treatment which 
has given us excellent results is incision of the sac with expression of the 
contents. This avoids the troublesome dissection of the sac and is less 
objectionable to the patient. After the preliminary preparation, a 
small amount of 0.5 per cent novocain is injected into the skin directly 
over the ganglion, and the hand flexed so as to render the sac tense. 
The sharp point of a scalpel is then plunged directly into the ganglion, 
and pressure made so as to express the contents. The inner surface 
of the sac is then swabbed out with tincture of iodine, and a pad 
strapped over the empty sac to secure pressure. If care is taken to 
make the puncture wound not over one-fourth of an inch long, a suture 
is unnecessary. Approximately two-thirds of the cases are cured by 
this means. Immediately after the operation there is usually slight 
swelling and edema but this disappears in a few days. 

After any of the above methods the following treatment is carried 
out. By means of a pad, placed over the ganglion and strapped in 
place with adhesive plaster, constant pressure is applied for about two 
weeks. 

Synovial Warts.— Closely related to ganglion in its clinical mani- 
festations is the so-called " synovial wart" of the skin. It is not a true 
wart but a cystic swelling in close relation to one of the subcutaneous 
bursa?. The following description by Hyde is probably the best that 
has appeared. 1 He states that lesions of this type: 

"Occur in the form of wart-like projections from the skin, pseudo- 
vesicles and bulla?, always over the sites of bursa? connected with 
tendons, traversing the small articulations of the hand and foot. They 
are seen over the metatarsophalangeal articulations; and in the hand 
most frequently over the dorsal face of the articulation between the 
distal and adjacent phalanges of the index finger and thumb. The first 
form is that of a roundish, corneous, pea-sized wart with a yellowish 
center, of long duration, usually insensitive unless roughly handled. 
When punctured there exudes a syrupy, yellowish, or grumous fluid 
which continues to form after repeated puncture. Split-pea-sized 
vesicles, and bulla? as large as a fifty cent piece, often exceedingly 
painful, are also seen, especially on the feet, with simply an epidermic 
roof wall. Each lesion contains the same yellowish, or whitish fluid, 
occasionally mingled with masses like sago grains. In every case the 

1 Quoted by Sutton: Jour. Amer.. Med. Assn., February 19, 1916. 



MALIGNANT TUMORS OF THE ARM AND HAND 



347 



contents of the lesions are supplied by a synovial bursa beneath the 
skin, with which the lesion is either directly connected, or in com- 
munication, by a short sinus." 

Treatment. —These lesions are very resistant to treatment. Excision 
with complete destruction of the cyst wall was advised by Hyde. 
Favorable results have been reported following electrolysis. We have 
seen these lesions permanently cured by roentgen ray. Puncture 
alone will have little influence. 




Fig. 246. — Synovial cyst on back of finger communicating with joint, intermittently 
opening and discharging synovial fluid. Painful when closed. Duration, over one year. 

MALIGNANT TUMORS OF THE ARM AND HAND. 

Carcinoma.— The ordinary forms of carcinomata rarely occur on 
the upper extremity except metastasis from growths primary elsewhere 
in the body. The metastatic tumors occur chiefly in the subcutaneous 
tissues and the bones. When they occur in the phalanges, they 




Fig. 247. — Rodent ulcer on the arm of a man, aged eighty-two years. 

cured by skin-grafting. 



Excised and 



resemble tuberculosis or syphilis. Such cases should be kept in mind, 

as they are occasionally the first symptoms noticed of internal cancer. 

Epitheliomata of the hand (usually the extensor surface) are not 

infrequently seen in people past fifty years of age. They begin as 



348 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

small ulcerations, originating at the location of small fissures or 
scratches on the back of the hand. They grow very slowly and have 
the same general characteristics as the slow-growing epitheliomata of 
the face. Removal by excision of the ulcer with a small amount of the 
surrounding skin is the best method of treatment. Recurrences are 
rare. 

Sarcoma.— Sarcomata of the upper extremity may arise from the 
skin, the fascia, or the bones. The lesion can apparently exist for 
years as a slow-growing tumor resembling fibroma, and then suddenly 
take on a malignant character. In other cases the tumor is malignant 
from the start. In the humerus, or other long bone, the first sign may 
be a so-called spontaneous fracture, in which case the growth must be 
differentiated from bone cyst. The similarity of sarcoma and fibroma 
has already been mentioned. 




Fig. 248. — Roentgenograph of sarcoma of bone in a Chinaman aged forty-five years. 



Treatment.— Because sarcoma may exist as an apparently benign 
tumor, every small growth of the hand and arm should be removed 
in its incipiency. If the tumor has reached a large size, in which wide 
removal will probably result in the sacrifice of important structures, 
it is permissible to remove a portion of the growth for microscopical 
examination. If the report is a benign tumor, the growth may be 
dissected away close to the tumor mass; but if malignancy is present, 
a wide dissection should be made even at the expense of important 
structures. In this condition, the best expert advice obtainable should 
be secured. Certain bone sarcomata can be removed by simple osteo- 
tomy and curettage, while others demand immediate amputation. 
The small sarcomata of the soft parts which resemble fibromata do not 



CONGENITAL DEFORMITIES OF THE ARM AND HAND 349 

require the removal of a large amount of surrounding tissue. An 
incision which is at least one quarter of an inch from the tumor mass at 
every point is usually all that is necessary. 

CONGENITAL DEFORMITIES OF THE ARM AND HAND. 

Deformities of the arm and hand may be congenital or acquired. 
Acquired deformities are the most common, resulting usually from 
cicatricial contraction following wounds or infection. 

The congenital deformities, which may properly be included under 
minor surgery, are usually represented by an excessive number of 
fingers or by the abnormal development of the fingers. 




Fig. 249. — Supernumerary fingers and toes. Six fingers on each hand with meta- 
carpal bones. Six toes on right foot, seven on left. Nails of great toes bifid, giving 
appearance of fused toes. 



Polydactylism. — This affection consists in the presence of one or 
more supernumerary fingers. The extra finger may be fully developed 
and attached to the bone by a true joint; or it may be only partially 
developed and attached to the normal bones by a fibrous band. The 
extra finger usually extends from the outer side of the first metacarpal 
bone in the shape of an extra thumb, or from the ulnar side of the fifth 
metacarpal bone as an additional little finger. Very rarely there may 
be an extra metacarpal bone. The condition of the bone may be 
clearly seen in roentgenographs made of the deformed hand. 

Treatment.— The extra finger should always be removed. Even 
if the patient has some functional use of the finger, the disfigurement is 
enough to indicate removal. As the bones shape themselves during 
growth, it is important to remove the finger before the hand develops. 
Children are usually brought to the eHnic during their second year, and 



350 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

it has been our custom to operate at once. Excision should be com- 
plete ; but if the finger articulates with the metacarpal bone, care should 
be taken not to injure that bone or the normal joint. If the joint is 
opened, the hand should be carried in a splint until healing is complete. 




Fig. 250. — Supernumerary fingers, pedunculated. 

Syndactylism.— Syndactylism, or web-finger, is the abnormal grow- 
ing together of the fingers, that is, an abnormal extension of the normal 
web of the fingers. It may be partial or complete; and may involve 
only a single web joining two adjacent fingers, or the whole hand may 
be in one mitten-shaped mass. A similar deformity may follow severe 
burns of the hand. A roentgen ray should be taken to show the 
condition of the phalanges, and if the bones are united, no operation 
is indicated. 




Fig, 251. — Clubbed fingers. Congenital heart. 

Treatment.— Didot's operation should be performed early in life, so 
that the hands and fingers may develop normally. The chief difficulty 
encountered is the healing of the fingers, together with the recurrence 
of the web. If the fingers are simply cut apart, the web is almost 



CONGENITAL DEFORMITIES OF THE ARM AND HAND 351 

certain to extend slowly toward the end of the finger as healing by 
granulation occurs. To prevent this, the incision should be made on 
the dorsum of one finger and the flap dissected toward the attached 




Fig. 252 




Fig. 253 
Figs, 252 and 253.— Bilateral webbing of ring and little finger, Bight less extensive, 

having been operated upon. 



352 TUMORS AND DEFORMITIES OF THE ARM AND HAND 




Fig. 254. — Congenital deformity of 
the hand. Note compensatory increase 
in size of little finger. 



finger. A second longitudinal incision is then made on the palmar 
surface of the other finger, and this flap dissected toward the first. 
If this has been correctly carried out, the palmar flap is attached to one 
finger and the dorsal flap to the other. The interphalangeal attach- 
ments are divided and the exposed 
surfaces of the fingers covered with 
the flaps which are held in place 
by fine silk sutures. We have 
found that the following modifica- 
tion adds greatly to the success of 
Didot's operation. 

A square flap, a little greater 
than the base of the web, is mapped 
out on the palmar surface of the 
web. This flap is dissected loose 
by cutting along its lateral and 
distal boundaries, and is then laid 
back on the palmar surface. A 
transverse incision, the width of 
the web, distal and parallel to the base of the flap, is carried through 
the base of the web, giving a transverse slit on the dorsum equal to the 
width of the web, and situated slightly proximal to the base of the 
flap. The flap is then passed through its opening so that its distal 
border appears on the dorsum of the web. This 
is attached by fine silk or horsehair sutures to 
the proximal side of the dorsal incision. This 
forms a normally placed web, proximal to the 
abnormal web, which is allowed to heal before 
Didot's operation is performed. The prelimi- 
nary flap effectively prevents recurrence even 
in syndactylism due to cauterization following 
burns. If desired, the flap may be fashioned 
from the palmar aspect and sutured on the back 
of the hand. 

Agnew's operation consists in the use of a 
Y-shaped flap made from the dorsum of the 
hand, with the point of the V pointing toward 
the end of the fingers and located about the 
region of the first joint. This is dissected back, the fingers are sepa- 
rated, and the flap is sewn into position between the fingers. If 
primary union occurs, the flap will prevent recurrence of the web, 
and is applicable where the web is not too thick. 




Fig. 255.— Webbed 
fingers. 



ACQUIRED DEFORMITIES OF THE ARM AND HAND. 

Dupuytren's Contraction.— This is a contraction of the palmar 
fascia with deformity of the ring and little fingers. The deformity 



ACQUIRED DEFORMITIES OF THE ARM AND HAND 



353 



in the milder cases consists only of the slightest degree of flexion of the 
metacarpophalangeal joint, but in the severer cases both fingers 
may be completely flexed, so that the ends of the fingers are firmly 
fixed against the palm, or all the fingers may be involved. The 




Fig. 256. — Dupuytren's contraction. Photograph shows greatest possible extension. 

thickened fascia may be felt as firm cords or bands, when an attempt 
is made to extend the fingers. 

The etiology is not clear. Many cases occur in workingmen (store- 
keepers, carpenters, shoemakers, etc.), who expose the palm to repeated 
trauma, but cases are sometimes 
seen in desk workers and others 
who have no history of trauma. 
The disease is usually progres- 
sive. 

Treatment.— In the early stages 
something can be accomplished 
by passive motion and massage, 
but in fully developed cases noth- 
ing avails except excision of the 
thickened fascia. 

The operation may be per- 
formed under local anesthesia if 
care is taken to block all the 
nerve fibers which supply the 
palm. A longitudinal incision 
is made along the palm over the 
most prominent part of the con- 
traction, and the skin is dissected 

away from the fascia on each side of the incision, the dissection being 
made close to the fascia so that the skin-flap may be as thick as possi- 
ble. The thickened fascia is then divided and dissected free from the 
tendons and the muscles in the palm and removed. This operation 
must be done slowly and carefully because the thickened fascia is 
adherent by many fibrous, bands to the deeper parts. After the fascia 
23 




Fig. 257. — Trigger-finger. After other 
fingers were fully extended, ring finger 
would extend with a snap. Broken and 
clubbed vincula found and removed at 
operation, result cure. 



354 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

has been entirely removed, the skin is sutured and the hand fixed 
upon a splint with the fingers extended. Motion of the fingers is 
begun after about a week, but the splint should be worn for several 
weeks. We have found it convenient to arrange a splint so that the 
fingers involved can be held extended while the patient is allowed the 
use of the rest of the hand. 

Where the entire palm is involved in the contracture, a U-shaped 
incision is made, with the convexity of the U at the base of the fingers 
and the sides of the U passing up along the sides of the palm. Longi- 
tudinal incisions are made from the convexity along the fingers, in order 
to remove the extensions of the process which extend along the fascial 
covering of the fingers. The flap is dissected back and the entire 
palmar fascia excised. In old cases this may require the loss of some of 
the skin, in which case a pedunculated skin-flap is required to fill in the 
defect. The skin is carefully sutured with horsehair or silk, and the 
hand kept extended on a splint for three weeks. This rarely fails to 
result in cure. In some cases the roentgen ray has been used with 
favorable results. 




Fig. 258. — Deformity of the hand, following total destruction of skin of the palm 
and dorsum. Successful skin-grafting, with early use of machines, resulting in fair 
function. 



Cicatricial Contraction.— Following the healing of burns or after 
operations for cellulitis of the hand, almost every conceivable type of 
contraction may exist. The fingers may be permanently extended or 
permanently flexed; or the fingers may be flexed while the wrist is 
extended; or the fingers may be normal but useless, because of the 
hyperflexion of the wrist. In any case a careful study of the mechanism 
of the deformity should be made before operation is begun. The joints 
should be roentgenographed to determine if a part of the deformity is 
due to bone or joint change. In burns of the fingers syndactylism 
may result. 

Treatment. — In a few cases, division of the contracting band will be 
sufficient to relieve the deformity; but in most cases, when the divided 
band heals, the resulting scar contracts as firmly as the first. 

A better plan of treatment is to divide all the contractures trans- 
verselv, until the fingers can be moved through the normal range of 



ACQUIRED DEFORMITIES OF THE ARM AND HAND 355 

motion. This will leave a denuded area which should be covered with 
a skin-graft. If possible, the graft should be in the form of a peduncu- 
lated flap; but if such a flap is not available, a Wolfe graft may be used. 
If neither of these methods is practicable, a Thiersch graft may be used ; 
but it should be remembered that there is likely to be considerable 
contraction after this form of skin-grafting. In certain cases it is wiser 
to remove completely a considerable area of cicatrix and apply a graft 
over this entire denuded area. This will sometimes result in less 
deformity than that which follows simple division of the scar. 

After operation the hand should be fixed in a splint in a position of 
overcorrection and kept in this position until healing is complete. 
Passive motion and massage should be practised for several months to 
prevent the recurrence of the deformity. 

In the severer types of deformity, especially those which have 
persisted for a long period, it may be necessary to lengthen the tendons 
and to divide the shortened ligaments. In some cases the shape of the 
bones and joints has been changed so that complete restoration of 
function is impossible. In any case the results are often unsatisfactory 
and the prognosis should be guarded. Syndactylism due to burns 
should be treated in the same manner as the congenital deformity. 

Ischemic Muscular Paralysis (Volkmann's Contracture; Ischemic 
Myositis; Ischemic Muscular Atrophy).— Volkmann, in 1875, described 
severe contractions of the hand following the use of tight bandages 
applied to the forearm to hold splints in cases of fracture. He demon- 
strated that the paralysis and contractures occurred simultaneously, 
and thought that the condition was due to the death of the muscles 
because of insufficient blood supply, and that it was similar to rigor 
mortis. Since Volkmann's paper it has been shown that the condition 
may follow ligation of a large artery, the prolonged use of a tourniquet, 
the application of an Esmarch bandage, crushing injuries in the region 
of the elbow-joint, and thrombosis of the arteries or veins. The con- 
tracture is a degeneration of the muscles, followed by induration and 
spontaneous contracture. It is more common in children than in 
adults, and is most frequently seen in the muscles of the forearm. It 
develops very rapidly, sometimes in three or four hours, and often in 
less than twenty-four. The fingers are contracted into the palm and 
cannot be extended either actively or passively. In severe cases the 
wrist is held in fixed flexion. Examination of the forearm may show 
evidences of beginning pressure sores due to tight splinting. There is 
usually little or no pain, unless there is an accompanying neuritis, 
when pain may be severe. Cases have been described in which the 
condition was due to interference with the venous return rather than 
to an arterial ischemia. 

Jones reports that in 19 cases due to fracture followed by ischemic 
paralysis, 13 showed marked malunion; and Dudgeon has remarked 
the fact that in children the growth of the bone may be interfered with. 
In old cases the muscles show pronounced atrophy. 



356 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

Treatment. — 1. Preventive.— To prevent ischemia, extreme care 
should be taken in applying splints to the arm and forearm to avoid 
constriction. It should be borne in mind that although the bandage 
may be applied loosely at the time of treatment, subsequent swelling 
of the arm, due to extravasation of blood or fluid into the damaged 
tissues may so tighten the bandage that the circulation is interfered 




Fig. 259 Fig. 260 

Figs. 259 and 260. — Volkmann's contracture seven weeks after greenstick fracture of 
radius and ulna with compression of median and ulnar nerves. (Ashhurst.) 

with or completely cut off. The same results have been seen following 
the application of a tight bandage around the elbow and later flexing 
the arm so that it could be carried in a sling. 

If the cases are seen early, the splint or bandage should be removed 
at once and efforts made to increase the blood supply by the use of 




Fig. 261 Fig. 262 

Figs. 261 and 262. — Eight weeks after operation (lengthening of all superficial and 
deep flexors, and neurolysis of median and ulnar nerves). Patient was able to play 
the piano just as well as before injury. (Ashhurst.) 



heat and light massage. Unfortunately, because of the absence of 
pain, most cases are seen after the contracture has occurred. 

2. Conservative treatment consists in active and passive motions to 
increase the length of the flexor muscles and to break down adhesions. 
This requires painstaking care and treatment, persisted in for several 
months. Some form of apparatus may be used to maintain the increase 



ACQUIRED DEFORMITIES OF THE ARM AND HAND 357 

of movement each day; but these splints should not be left on too long, 
for the skin is especially subject to the development of pressure sores. 

Sayre advises the use of the Jones' method of treatment which consists 
of active motions to increase extension. 1 Jones flexes the wrist, thus 
permitting complete extension of the fingers. The fingers are splinted 
in the extended position, and the patient is urged to extend the meta- 
carpophalangeal joints. When this movement is increased, the entire 
hand is held extended on a splint, and the patient is required to practice 
extension at the wrist. Each day the hand and forearm are splinted 
in such a way as to maintain the increased extension. Usually after a 
few weeks the hand may be completely extended and this position is 
held by splints for a month or more, until the tendency to contracture 
has disappeared. 

Operation as a rule is not advisable, because of the danger of infection 
in tissues of scanty blood supply. It should never be attempted until 
conservative measures have failed. Division of the muscles and 
tendons has been advised for practically hopeless cases. Lengthening 
of the tendons and stretching of the nerves are of value when there is 
only a slight return under prolonged conservative treatment. Shorten- 
ing of the bones of the forearm by excision of a portion of each bone 
has been advocated. In children it is inadvisable, because of the 
tendency to interfere with bone growth. 

Deformities Secondary to Nerve Injury.— Paralysis of the nerves 
may be followed by deformities of the arm and hand. Infantile 
paralysis is a frequent cause of atrophied and deformed hands. In 
some cases it is so marked as to make the extremity practically useless, 
and in others it is so slight as to cause only slight disability. Traumatic 
injury to the nerves in the region of the arm or forearm causes paralysis 
of the muscles supplied by the injured nerve, followed by contractures 
of the opposing muscles, and resulting in permanent deformity. The 
symptoms and character of the deformity depend upon the nerve 
involved and the extent of injury. In neglected cases the contracted 
muscles become fibrous in character, so that extension even under an 
anesthetic is impossible. 

Treatment.— The treatment is largely preventive. When paralysis 
develops from whatsoever cause, the arm and hand must be supported 
by splints so as to oppose the pull of the unaffected muscles. In 
applying the splint, care must be exercised to prevent the occurrence 
of pressure sores. The splints should be removed frequently for light 
massage and stimulation of the paralyzed muscles. 

If the condition is due to the traumatic division of a nerve or pressure 
upon the nerve by a fragment of bone or callus formation, the necessary 
operative procedures should be instituted at once for the repair of the 
nerve or the relief of the pressure. The splints should be continued 
until function returns or until there is no hope of further recovery, in 

1 American Journal of Orthopedic Surgery, November, 1908. 



358 TUMORS AND DEFORMITIES OF THE ARM AND HAND 

which case a brace should be worn to hold the part in the normal 
position. Thus, a patient with drop-wrist, who has almost no use of 
the hand in the position of wrist-drop, has a fairly strong grip, if the 
hand is held extended with a firm brace. 

Muscle-, tendon- and nerve-grafting have all been advised for the 
relief of paralyzed muscles of the arm and hand. The operations 
devised have been successful in certain selected cases. They are, 
however, largely dependent upon the individual skill of the operator 
and are not suitable for general application. 



CHAPTER XIII. 

FRACTURES AND DISLOCATIONS OF THE LOWER 

EXTREMITY. 



MINOR FRACTURES OF THE THIGH. 

Many fractures and dislocations of the lower extremity are hospital 
cases, and a description of their management would be out of place 
in a work on minor surgery. There are, 
however, a considerable number which 
are seen in office practice and it is of these 
less serious fractures that the following 
pages treat. 

Fracture of the Neck of the Femur.— 
While in most cases of fracture of the neck 
of the femur there is complete loss of func- 
tion, occasionally a case presents itself to 
the surgeon with the following history : 

After a fall on the affected side, the 
patient was unable to stand or use the 
involved hip; but after a few days' rest 
in bed, he was able to walk with but a 
slight limp and a moderate amount of 
pain in the hip. The persistence of this 
pain caused the patient to visit the clinic. 

The roentgen-ray picture in such a case 
usually reveals an impacted fracture of 
the neck of the femur with slight deform- 
ity. 

Treatment.— As such cases are rarely 
seen until the union is firm, the treatment 
consists chiefly of measures to relieve 
the pain, namely, massage, manipulation, 
counter-irritation, hydrotherapy. If seen 
early, although the patient has been using 
the hip he should be put to bed for sev- 
eral weeks and given daily massage. 

This injury should always be suspected 
in elderly persons in whom a trauma has 
been followed by lameness and pain in 
the region of the hip. 

Fracture of the Greater Tuberosity.— This is a rare condition usually 
caused by direct trauma, but which may occur as a result of muscular 




Fig. 263. — Impacted fracture 
of the femur in a child^ aged 
three years. No loss of func- 
tion. 



360 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

action. The fractured fragment is likely to remain partially attached 
to the femur by tendinous and periosteal fibers. The symptoms are 
local tenderness and pain referred to the region of the tuberosity when 
the hip is rotated inward. 

Treatment.— The treatment consists in rest in bed with the thigh 
rotated outward. Union is usually satisfactory after three or four 
weeks, although pain may persist for several months. 

Fracture of the Lesser Trochanter.— This injury is probably more 
common than is ordinarily supposed. Most of the cases reported have 
occurred during the last few years, since the advent of the roentgen 
ray has permitted an accurate diagnosis to be made. Muscular action 
is the most important etiological factor, the patients usually giving a 
history of a sharp pain while running or jumping, followed by disability. 
Most of the cases occur in boys about seventeen years of age, in which 
cases the injury is probably due to a separation of the tuberosity at 
the epiphyseal line. In one case recently reported, the patient was 
able to walk after the accident ; but the ordinary history is that of 
disability which occurs suddenly and is complete. Pain and inability 
to flex the hip are the most striking symptoms. 

Treatment.— The treatment consists in rest in bed with the thigh 
flexed to relax the psoas muscle. Operation is rarely justified. 

Fracture of the Epicondyle.— Fracture of the internal epicondyle of 
the femur occurs fairly often. The fragment consists of a small piece of 
bone about half an inch in width separated from the inner condyle 
of the femur. The location of the fracture is marked by the insertion 
of the tendons of the adductor magnus muscle and the muscular attach- 
ment of the inner head of the gastrocnemius. This injury is frequently 
caused by muscular violence, but it may occur as a result of a blow upon 
the inner aspect of the thigh and is often associated with effusion into 
the knee-joint. A similar fracture may be caused by the separation 
of the adductor tubercle as the result of a sudden contraction of the 
adductor magnus muscle. The adductor tubercle may be greatly 
increased in size, especially following horseback riding, and the enlarged 
tubercle is very easily fractured. The symptoms are local tenderness 
and pain on adduction of the thigh against resistance. When there is 
only slight swelling, the fragment may be distinguished and. moved 
about beneath the skin. This injury may be differentiated from a 
dislocation of the internal semilunar fibrocartilage by the location of 
the point of acute tenderness which is at the upper and posterior part of 
the internal condyle in fracture of the epicondyle, and below the 
condyle in separation of the meniscus. 

The enlarged adductor tubercle of horseback riders is commonly 
felt as a well-defined lump on the inner side of the thigh just above the 
inner condyle of the femur. If it is fractured, false point of motion, 
with pain and crepitus, is usually present. 

Treatment.— The treatment of fracture of the epicondyle or of the 
adductor tubercle consists in rest in bed, with treatment directed 
toward the relief of complicating effusion into the knee-joint with 



FRACTURE OF THE FAT ELL A 



361 



fixation of the joint in a position of partial flexion. A posterior molded 
plaster splint serves admirably for this purpose. Recovery, after rest 
for a few weeks, is usually complete. Operation may be advised, if 
there is considerable disability following treatment, or if there is a 
considerable amount of separation. 




Fig. 264. — Roentgenograph of a compression fracture of the head of the tibia caused 
by downward pressure of the outer condyle of the femur in forcible abduction of 
the leg. 



FRACTURE OF THE PATELLA. 

In cases due to muscular action, the separation of the fragments is 
usually marked, and the patient is able to walk only with great diffi- 
culty. The diagnosis is easy and based upon: (1) The inability to 
extend the leg against gravity; (2) the easily palpated transverse groove 
between the two fragments; (3) the independent mobility of the 
fragments. The knee-joint is swollen almost immediately, the con- 
tents, as a rule, consisting of blood mixed with synovial fluid. A 
fracture should always be suspected, even though some of the cardinal 
symptoms are absent. If there is acute tenderness over a more or less 
localized area on a bone, it points to fracture. When in doubt, it is far 
safer to diagnose a fracture and advise roentgenographic examination 
to prove or disprove the diagnosis, than it is to deny the possibility of 
fracture, especially in these days when roentgen-ray pictures play such 
an important part in law suits. 

In fractures the result of direct violence, the symptoms may be as 
severe as those due to muscular action, but are commonly much less 
clearly defined. The line of fracture may be transverse or it may run 
in any direction. Comminuted fractures are not uncommon. The 
patient is frequently able to walk, and the knee may sometimes be 
extended against gravity. The diagnosis is made by local tenderness 



362 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

along the line of fracture, pain on attempts to extend the leg against 
resistance, and irregularity of the surface of the bone. Fractures due 
to muscular action belong to major surgery, so that only their 
temporary treatment may properly be considered under minor surgery. 
On the other hand, fractures of the patella due to direct violence, 
except when there is displacement of one of the fragments, may remain 
under minor surgical treatment from the start. 

Treatment.— The treatment of fracture of the patella may be divided 
into non-operative and operative. In both of these, a few days' 
preliminary rest in bed, with cold applications and pressure, is neces- 
sary for the control of the effusion and hemorrhage into the joint. 
Where the swelling is very marked, puncture and aspiration of the joint 
fluid may occasionally be indicated, but, as a rule, this is unsatisfactory 
because the large clots of blood are apt to clog the lumen of the aspirat- 




Fig. 265. — Stellate fracture of the knee; direct trauma; slight disability. 



ing needle. After the fluid has been removed, its recurrence may be 
opposed either by compression with a roller bandage or by adhesive- 
plaster straps made to cover the entire knee, except the posterior aspect 
of the joint. The leg should be placed in the position which relaxes 
the quadriceps muscle, that is, in a position of slight flexion of the hip. 
If there is no separation of the fragments, the knee may be slightly 
flexed; but, if the fragments show separation, the leg should be elevated 
in complete extension. 

Non-operative Treatment— This is the method of choice when there 
is no displacement. After the swelling has begun to subside, the 
treatment depends upon the type of fracture. 1 In longitudinal frac- 

1 In general, fracture due to direct violence without displacement of the fragments 
into the joint, which is rare, is well splinted by the lateral ligamentous expansions and 
the treatment is directed to the associated injuries, such as, effusion into the joint, con- 
tusions, etc. In fracture due to muscular action, the ligamentous expansions on both 
sides of the joint are widely torn and the treatment is primarily a tenorrhaphy to repair 
these tears. 



FRACTURE OF THE PATELLA 363 

tures and others where there is no tendency to separation, it is only 
necessary to keep the patient in bed for two or three weeks. After 
this time the leg should be fixed in extension by a posterior molded 
splint or by a plaster bandage, and the patient allowed to be up and 
about. 

In cases with displacement, if the non-operative treatment is decided 
upon, the patient should be kept in bed with the leg slightly elevated 
and the knee-joint extended. This position may be maintained by a 
wooden splint or by a posterior molded plaster splint extending from 
the upper thigh to a point on the leg just above the ankle. 

There are several methods which tend to cause approximation of the 
fragments. In some cases a snug bandage, which covers the leg and 
thigh above and below the knee, but leaves the patella itself free, seems 
to exert a favorable influence in forcing the fractured surfaces together. 
Fixed traction may be attempted by strips of adhesive plaster crossed 
above the patella and attached to the skin or to the splint below the 
joint, combined with similar strips crossed below the patella and 
attached above. It is impossible to say how much influence these 
bands have upon the fragments. Elastic traction is secured in the 
same manner as fixed traction, except that a rubber band or piece of 
elastic tubing is connected at the insertion of the adhesive plaster in 
such a manner as to secure constant tension. 

Early massage has been advised as a means of removal of the 
effusion and as a measure to cause rapid healing of the fracture. In 
this method of treatment, the leg is kept extended on a splint, which 
is removed for daily massage. The leg and posterior thigh are mas- 
saged upward to remove the accumulated exudate; but the anterior 
thigh is massaged always downward to effect elongation of the quadri- 
ceps extensor muscle. This method hastens the absorption of the 
exudate and improves the circulation. It seems to cause an appreci- 
able shortening of the period of convalescence and frequently results 
in an excellent anatomical and functional result. Rest in bed is 
usually necessary for a month or six weeks. After this time the patient 
is allowed to go about on crutches with the leg in a firm posterior 
plaster splint. The patient is allowed to bear the weight on the 
injured leg, the crutches being merely used as a protection against a 
sudden fall. Premature flexion, or even strong contraction of the 
quadriceps with the leg firmly extended, may cause retraction of the 
upper fragment with recurrence of all the symptoms. Consequently, 
falls and accidents should be carefully guarded against. The period 
on crutches lasts about three weeks, during which time the splint is 
removed daily for massage and slight passive motion (10 degrees to 
20 degrees at the knee). After the eighth or ninth week, the splint is 
removed entirely, but the patient is warned not to use the leg in stair- 
climbing or in other motions which throw a strain upon the patella, 
for at least a month. 

In another method of treatment the attempt has been made to hold 



364 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

the fragments in place by means of a circular plaster bandage, which 
is indented above and below the patella. The indentations are made 
by pressure upon the bandage while it is being applied. This is some- 
times desirable in cases where the patient is under only limited control, 
as in certain types of dispensary practice, and in cases where the 
surgeon is unable to devote sufficient time to the details of treatment 
as outlined above. It is often undesirable because, with the sub- 
sidence of swelling in cases of considerable effusion into the joint, the 
cast may become loosened and fail to accomplish the purpose for which 
it w r as applied. 

Operative Treatment. — The only form of operative treatment worthy 
of mention is incision of the joint with suture of the fragments. Owing 
to the danger of infection in all operations which involve the opening 
of a joint, and especially in the case of the knee-joint, any operative 
proceeding should be approached with a great deal of conservatism. 
The knee-joint should be opened only by a skilled surgeon under the 
strictest aseptic precautions. In the modern hospital under the best 
conditions the knee-joint may be operated upon with comparatively 
little danger. 

Under suitable surgical care and with proper aseptic surroundings, 
operation is indicated when: 

1 . There is separation of the fragments, which can be approximated 
only with great difficulty. 

2. One or both of the fragments are rotated so that the fractured 
surface cannot be brought together. 

3. The separation is only moderate, but the patient's livelihood 
depends upon active use of the leg. 

4. There is apparently ligamentous material between the fragments. 
Operation is contraindicated if: 

1. There is no separation. 

2. The separation is slight in elderly subjects and in others leading 
a sedentary life. 

3. There is any superficial infection, or a wound or abrasion likely to 
become infected. 

4. The surgeon has not the necessary experience or the operating 
facilities are not of the best. 

In patients to whom a long period of convalescence is not a hardship 
and in whom a moderate degree of disability is not a hindrance to the 
pursuit of a livelihood, the indications and contraindications should 
be carefully weighed. The treatment chosen should depend largely 
upon the decision of the patient, especially where the separation is 
slight or moderate (up to half an inch) . Given the proper conditions 
for the performance of the operation, it is well to advise operation in 
every case of separation (whether the fragments can be approximated 
or not) in working men who require a strong union for the activities 
necessary to their work. 

For the disability which often follows either bony or fibrous union, 



MINOR FRACTURES OF THE LEG 



365 



massage and mechanotherapy are advised. In a few cases, hyper- 
trophy of the patella after either operative or non-operative treatment, 
may be so marked as to interfere with movement. In other cases 
where, following conservative treatment, there is an elongated con- 
nective tissue-band between the fragments, the upper fragment may 
interfere with flexion and require secondary removal. Secondary 
operations for the suture of the patella several weeks or longer after 
injury are often unsuccessful because of the contraction of the extensor 
muscles. 

MINOR FRACTURES OF THE LEG. 

Separation of the Tubercle of the Tibia.— This is apparently a 
fracture-separation of the epiphysis, and is caused by a violent muscular 
effort, such as running or jumping. The tubercle of the tibia is a 
downward prolongation of the upper epiphysis and is not joined to the 
shaft of the bone until after the twentieth vear. 




Fig. 266. — Separation of the patella tubercle of tibia, right, with hemorrhagic infiltra- 
tion of the surrounding tissues. 

Epiphyseal separation is not likely to occur before the epiphysis 
is well formed or during the period when ossification is complete or 
nearly so. In the case of the tibial tubercle, separation occurs almost 
exclusively after the twelfth and before the nineteenth year. 

On examination the movable fragment can be felt beneath the skin, 
and when it is moved against the tibia, crepitus can sometimes be 
distinctly felt. In most cases crepitus is absent. There may be an 
associated effusion into the joint. Roentgen-ray examination shows 
the fragment separated from the tibia; but care must be taken not to 
confuse the very distinct epiphyseal line of a boy of twelve or fourteen 
with a pathological separation. 

Treatment.— The treatment consists in a posterior molded splint, 
which keeps the knee extended, combined with adhesive-plaster strips 
applied so as to hold the fragment in place. The splint should be worn 
for from four to six weeks, the patient being allowed to walk about 



366 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

after the acute symptoms have subsided. The strapping requires 
repeated reapplication every week or ten days for two or three months. 
Pain, tenderness, and a slight degree of disability may persist for several 
months or a year. Separation is seldom more than a small fraction of 
an inch, so that operative treatment is rarely called for. 

Fracture of the Fibula.— The fibula may be fractured at its upper 
end by the contraction of the biceps or by the strong external lateral 
ligaments in forced adduction of the leg. The fragment may be widely 
displaced upward. It should be treated by fixation of the knee to 
prevent secondary adduction at the knee-joint and, theoretically, in a 
position of partial flexion to relax the biceps. However, there is 
seldom any great disability, even when the leg is fixed in extension. 




Fig. 267. — Roentgenograph of the compression fracture of the head of the fibula from 
falling two stories and landing on the feet. 

A rather frequent complication is paralysis of the peroneal nerve from 
rupture, or from pressure due to callus occurring where the nerve turns 
about the neck of the fibula. 

Fracture of the Shaft of the Fibula.— Fracture of the shaft of the 
fibula is usually caused by direct violence. Owing to the fact that the 
bone is deeply situated among the muscles of the calf, palpation of 
the bone is impossible, and most of the ordinary symptoms (crepitus, 
bony irregularity, false point of motion, etc.) are absent. The most 
common symptoms are tenderness on pressure, pain referred to the 
region of the fracture, and pain on forcible manipulation of the foot 
against resistance. This last symptom is seen when the patient tries 
to raise his heels from the floor while bearing the weight upon the ball 



MINOR FRACTURES OF THE LEG 



367 



of the foot, and is due to the fact that this action is brought about in 
part by the muscles attached to the fibula. Any of these symptoms, 




Fig. 268. — Fracture of the fibula and separation of the inferior tibio-fibular articulation. 

except pain on deep pressure, may be so slight as to be easily over- 
looked. In injury to the leg in the region of the calf following direct 
trauma, it is almost impossible to exclude fracture of the fibula without 
a roentgenograph. The patient may 
walk without difficulty, and often has 
so few symptoms, that the fracture 
is unsuspected. The persistence of 
pain in the calf out of proportion 
to the injury received is always sug- 
gestive of fracture of the fibula. 

Treatment. — The treatment con- 
sists in rest in bed for a few days with 
the leg elevated, followed by the use 
of crutches, either with or without a 
plaster support, for a period of five 
or six weeks. Before the advent of 
the roentgen ray, it is highly prob- 
able that many cases of fracture of 
the fibula were unrecognized and 
received no special treatment. As 
we have no records of bad results, 
it is probable that, in general, they 
healed kindly without treatment. 
A patient recently presented him- 
self at the clinic in whom the 
roentgen rav showed fracture of the r , OKO a . , , , , ,, .... 

• 1 ii ii • i pi i • ** " • — Spiral fracture of the tibia. 

middle third 01 the fibula received Patient walked to the hospital. 




368 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

in a fall three weeks before. As the man had been walking about, 
in spite of fracture with slight displacement, the calf was merely 
strapped and he was allowed to continue to use the leg. In a few 
weeks the pain and slight disability had entirely disappeared. 

If the plaster bandage is used, it should not be applied until the 
swelling has begun to subside, and after its application, the circulation 
of the leg should be watched very carefully. In the leg, just as in the 
forearm, the vessels are located in fibrous, bony troughs, so that 
compression, with consequent ischemic contraction, is likely to occur. 
A patient, who came to the hospital recently for another condition, 
showed very clearly the bad effects of a tight circular bandage. The 
muscles of the entire calf were apparently reduced to a fibrous band, 
as a result of a plaster bandage applied for fracture several years 
before. 

FRACTURES ABOUT THE ANKLE. 

Fractures with gross displacement should never be mistaken for 
minor conditions, for even a very superficial examination will demon- 
strate the bony irregularity. However, when the ankle-joint is 
markedly swollen, considerable displacement is sometimes overlooked. 
In injuries to the ankle associated with disability and followed by 
swelling extensive enough to obscure the ordinary landmarks, there is 
only one safe rule. Diagnose every such injury as fracture and treat 
it accordingly. The diagnosis will be confirmed by the roentgeno- 
graph nine times out of ten. 

The description given below will apply only to those cases in which 
the swelling is slight or moderate and the condition appears on super- 
ficial examination to be a contusion or a sprain. There is no doubt 
that thousands of these fractures were treated as sprains before the 
advent of the roentgen ray. The old saying, "a bad sprain is worse 
than a break," was largely founded upon the fractures which were 
wrongly treated as sprains. 

Pott's Fracture.— The original fracture described by Pott and which 
bears his name consisted of the fracture of the lower fifth of the fibula 
caused by the sudden forcing outward of the external malleolus in 
hyperextension of the foot. The term, " Pott's fracture," has now 
come to signify several different lesions of the ankle with varying 
degrees of deformity, depending on the point where the force is arrested. 

Thus, in Pott's fracture from eversion, the strain first comes on the 
internal lateral ligament. If this is sufficiently forceful it will rupture 
the ligament, or, what is more common, tear away the tibial attach- 
ment of the ligament, the internal malleolus. The eversion continuing 
presents a wider diameter of the astragalus in the intermalleolar mortice 
which forces the two bones apart, tearing the inferior tibio-fibular 
ligament, or, more rarely, tearing away a portion of the tibia with the 
ligament. Further eversion, carrying the external malleolus laterally, 
fractures the lower portion of the shaft of the fibula. If the force is 



FRACTURE ABOUT THE ANKLE 



369 



arrested at this point there may be but slight deformity, although the 
three typical points of tenderness are present, namely, tenderness 
over the internal malleolus, over the inferior tibio-fibular articulation, 
and over the fractured fibula. If the force is continued, a marked 
deformity may be produced. 

The lines of fracture and the degree of ligamentous tear vary some- 
what according to the position of the foot during eversion. Thus, if 
the foot is extended, the force drives the foot backward, giving pos- 
terior displacement. If the foot is flexed, it will be driven forward, 
giving anterior displacement. Abduction and adduction also vary 
the line of fracture. 




Fig. 270. — Old untreated Pott's fracture. Marked disability. 



Forceful inversion of the foot, producing the so-called "inverted 
Pott's," may give the same lesions as the everted Pott's, although it 
is more common to see a fracture of the external malleolus or of the 
fibula accompanied by the tearing of the inferior tibio-fibular ligament. 

Treatment.— There is no part of the body where treatment demands 
more knowledge, skill and patience than the ankle. Here, a perfect 
anatomical result is necessary to produce anything approaching a 
normal functional result. 

All injuries to the ankle, no matter how slight they appear, should 
be roentgen rayed. Early and perfect reductions should be sought for. 
In bad fractures, repeated roentgen rays and inspection are necessary 
during the first three weeks, as immobility is often hard to procure and 
maintain. 

In cases where there is marked deformity, where the fracture is 
24 



370 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

compounded, or where there is extensive injury to the soft parts, the 
patient belongs to major surgery. Even in milder cases where the 
roentgen ray shows but slight deformity, the swelling of and injury to 
the soft parts may be sufficiently marked to require the application of 
a temporary splint 1 and rest in bed for a number of days. 





i . . , ^^^^m -ip 


■ ■■nil 



Fig. 271. — Long fracture box, for fracture of bones of leg. Note dry dressing over 
wound of compound fracture of tibia and foot bandaged to foot piece. (Ashhurst.) 

After a thorough and extensive study of injuries to the ankle, it is 
our opinion that with rare exceptions the most satisfactory treatment 
is to put the foot up in the normal position of rest, as in this position 
the astragalus has less tendency to wedge apart the malleoli and thus 




Fig. 272. — Long fracture box for fracture of bones of leg, sides raised and fastened 

around leg. (Ashhurst.) 

widen the joint. With this treatment, followed by early mobility and 
massage, we see fewer cases of the persistently stiff and painful ankle 
of the past. 

1 A box splint gives sufficient support and allows the extremity to be inspected and 
dressed with the least amount of disturbance. 



FRACTURES ABOUT THE ANKLE 371 

Where there is slight injury to the soft parts, where reduction has 
been easy, thus insuring slight after-swelling, and where the swelling 
has subsided and the blebs and other injuries have healed, a permanent 
dressing may be applied. In the selection of the permanent dressing 
the surgeon has a wide field of choice. We have found a very satis- 
factory dressing in the molded plaster splint, which varies in thickness 
and extent according to the demand. 

A light, comfortable splint giving perfect support and which is easy 
to remove and replace, thus facilitating massage and manipulation, 
can be made in the following manner: A 2-foot length of 2-inch muslin 
bandage is folded to form a guide 1 inch wide. This guide is laid along 
the anterior aspect of the leg, one end being held at the knee by adhesive 
plaster, the other being tucked between the great and adjacent toe. 
The leg is then completely covered by four or five layers of gauze 
bandage from the base of the toes to just below the knee. The leg is 
then ready for the plaster. 

A strip of flannel 3 x 32 inches is covered with twelve layers of 
plaster bandage. While still moist the middle of this strip is applied 
to the sole of the foot just in front of the heel, and the two ends of the 
strip are carried up along and molded to the sides of the leg, forming 
a stirrup splint which is held firmly in place by a few turns of gauze 
bandage. A light spica plaster bandage is then snugly applied, extend- 
ing from the base of the toes to about five inches above the malleoli 
and including the heel. 

The end of the muslin guide is then removed from between the toes, 
the blunt end of a pair of bandage scissors is inserted between its 
layers, and the overlying bandages are cut through, leaving no encir- 
cling bands either of gauze or plaster. The guide is then lifted out by 
pulling on both ends, and the entire splint is covered by a muslin spica 
bandage. 

Fracture of the Internal Malleolus. — Fracture of the internal 
malleolus may result from direct violence or from forcible eversion and 
is essentially the beginning of an ordinary Pott's fracture. There is 
little or no displacement of the foot, and swelling is often limited to 
the inner side. Usually the malleolus is not displaced. The injury 
is distinguished from sprain due to external rotation by the location 
of the line of acute tenderness, which is over the bone instead of over 
the internal lateral ligament. Patients are usually able to walk after 
the first few days, and sometimes immediately after the injury. 

Treatment.— The treatment consists of the application of an internal 
lateral molded plaster splint, passing from just below the knee along 
the inner side of the leg beneath the arch and around the outer margin 
of the foot and ending on the dorsum of the foot over the first meta- 
carpal bone. While the splint is hardening, the ankle is held at a right 
angle in normal inversion. As the splint is light and there is no 
tendency to displacement, the patient may be allowed up on crutches. 
The splint is removed frequently for massage and is discarded after five>' 



372 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

weeks; the ankle is strapped for support (see Sprain of the Foot), and 
the patient is allowed moderate functional use. The adhesive strap- 
ping is renewed every week for a period of three weeks. At the end of 
which time, full use of the ankle, properly supported by heavy lace 
shoes, should be encouraged. 

If preferred, the leg and ankle may be included in a plaster bandage 
rather than a molded plaster splint, the bandage passing from above 
the calf of the leg to the base of the toes. 

Fracture of the External Malleolus.— Fracture of the external 
malleolus by direct violence is more common than fracture of the 
internal. The fractures caused by indirect violence are considered 
under Pott's fracture. 

Treatment.— The treatment is similar to the treatment of fracture 
of the internal malleolus, the foot being put up in normal inversion. 
Although inversion tends to accentuate the displacement, the astragu- 
lus is more firmly held in place when the ankle is fixed in this position. 
If the bone is allowed to heal in the everted position, permanent 
eversion and weakening of the arch will almost certainly follow. If 
there is the slightest tendency to displacement, the foot should be kept 
in the internal splint above described for at least six weeks, after which 
the ankle should be supported by strapping and heavy lace shoes. 

Oblique Fracture of the Lower End of the Tibia.— Oblique fracture 
of the lower end of the tibia is another fracture that is frequently 
overlooked. The mechanism is not quite clear. Possibly it occurs 
in some cases of inversion before the fibula is injured, when there is 
at the same time a considerable degree of upward pressure through 
the astragalus. The line of fracture, when it occurs as a single lesion, 
is from the articular surface near the base of the internal malleolus, in 
an oblique antero-posterior plane upward and outward to the external 
aspect of the bone, about two or three inches from the lower extremity. 
The longitudinal fracture, occasionally seen, is probably an incomplete 
fracture of this type. 

Symptoms.— The symptoms are limited to tenderness and pain on 
extreme dorsal flexion of the foot. The patient may, or may not, 
be able to walk with this injury. The swelling is usually much less 
than is seen in fractures about the malleoli. When the line of fracture 
is more external, part of the weight-bearing surface of the tibia is left 
and the patient is often able to walk with comparatively little pain. 

Treatment. — The treatment consists of fixation for about six weeks, 
and after-treatment as above described in the case of fracture of the 
malleolus. 

Minor Complaints Following Fractures About the Ankle.— Certain 
sequelae of Pott's fracture occur in ambulatory practice and will conse- 
quently be discussed briefly. 

Stiffness of the ankle to a greater or less degree very frequently 
occurs. If there is no bony deformity, the stiffness is usually fibrous, 
although in some cases fragments of the bone or callus formation may 



FRACTURES ABOUT THE ANKLE 



373 



interfere with motion. In either case, passive motion, combined with 
massage, is to be advised. Functional use of the ankle is important. 
The patient should be encouraged to use the foot a great deal in spite 




Fig. 273. — Roentgenograph of fractures caused by jumping from a rapidly moving car. 

Foot driven backward. 




Fjg, 274.— Same case as shown in Fig. 273 after reduction. 



374 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

of pain. In ankle cases especially, the various forms of mechano- 
therapy are of great value. These are seen commonly in the familiar 
Zander Institutes where almost every conceivable type of apparatus, 
adapted to various motions of the joints, may be secured. 

Unfortunately, these machines are expensive and rarely available, 
but this difficulty can often be overcome by the construction of home- 
made machines to exercise the injured joint. Thus the foot may be 
strapped to a board six inches wide and twenty or more inches long, and 
a roller placed in the center so that the board and foot tilts back and 
forth, causing the foot to be alternatingly flexed and extended. If 
the fulcrum is run the long way of the board, the foot is everted and 
inverted. If this same board is made to work upon hinges on an axis 
running transversely through the board below the arch of the foot, the 
patient may sit in a chair and work the ankle back and forth against 
the resistance of a spring, which connects the end of the board and the 
floor. 

It should be remembered that the apparatus should be arranged 
either to move the foot or to swing it, so that the movement imparted 
by the patient tends to be increased. The familiar example of this 
tendency is seen in a simple apparatus which can be used after fracture 
of the shoulder. If the patient is told to swing the arm back and 
forth, there will be little increase in movement at the shoulder; but if 
he is given a bucket of water and told to swing it back and forth, the 
weight of the water tends to carry the arm a little further at each swing, 
and the motion at the shoulder is rapidly increased. All that is 
necessary is that this principle be followed in the construction of appa- 
ratus for the various movements of any injured joint. The exercise 
of a little ingenuity will enable the surgeon to suggest the type of 
apparatus best suited to the need of the patient. 

If, after a thorough course of mechanotherapy, there is still stiffness 
of the joint, the fibrous adhesions may be broken up under an 
anesthetic. If the movements are restricted by bones or callus- 
formation, and the cause is definitely shown in the roentgenograph, 
operation may be advised. 

Limitation of flexion is often due to the failure to fix the ankle in a 
position of dorsal flexion. The wide anterior portion of the astragalus 
cannot be moved backward between the malleoli, and the foot is held 
in a position of extension (plantar flexion), the patient being obliged 
to walk on the ball of the foot and unable to place the heel upon the 
ground in walking. 

If this condition is not marked, it is sometimes possible to correct 
it by forced dorsal flexion under anesthesia. If this fails, operation is 
indicated. 

Old unreduced fractures about the ankle show considerable deformity 
with loss of function. In these cases, mechanotherapy gives little or 
no relief. Operation is the only method of treatment which may be 
expected to result in improvement. Two operations have been 



FRACTURES OF THE TARSUS 



375 



advised: (1) Osteotomy; (2) arthrotomy and osteotomy. Osteotomy 
above the malleoli will permit the foot to be brought back into line with 
the tibia, but does not correct the backward displacement. Arthro- 
tomy and osteotomy bring the astragalus back into normal position by 
open operation. If the conditions are suitable for the strict asepsis 
necessary to bone- and joint-surgery, the latter operation is advisable. 




Fig. 275. — Impacted fracture of neck of right astragalus. (Ashhurst.) 



FRACTURES OF THE TARSUS. 

Fracture of the Astragalus.— The astragalus may be fractured by 
falls from a height, the bone being crushed between the os calcis and 
the tibia. When there is no displacement, the diagnosis is very 
difficult, the chief symptoms being swelling, local tenderness, and loss 
of function. In severe injuries, the fracture is comminuted, and false 
point of motion and crepitus may easily be made out. 

Diagnosis. —The diagnosis frequently rests upon the roentgen- 
ray findings. Where fracture of the astragalus is suspected, as well as 
in all other injuries about the tarsus, it is advisable to have plates taken 
of both feet so that a comparison of the normal and injured ankle may 
be made. 

Treatment. —The treatment consists of reduction of displacement 
by direct manipulation, and fixation of the ankle-joint at a right angle 
for five or six weeks. 

If the upper portion of the articular surface has been chipped off, 
or if the head is loose and displaced, it is better to remove the loose 
fragment by early operation. Function is often permanently impaired. 



376 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

If reduction has been satisfactory or if the loose fragment is removed, 
there may be a moderate return of function in three or four months. 
If, after this period, the ankle is still useless or nearly so, operation 
for the complete removal of the astragalus is indicated. This operation 
is followed by a considerable functional improvement in most cases. 

Fracture of the Os Calcis.— The os calcis is broken by falls upon the 
feet, the patient striking directly upon his heels ; or it may be broken by 
the contraction of the soleus and gastrocnemius. 

Symptoms.— In the direct form, the symptoms are indefinite. Swell- 
ing and local tenderness are prominent, serving to mask the other symp- 
toms. In a few cases, crepitus and false point of motion may be made 
out by direct manipulation. There is acute pain on attempts at plantar 
flexion of the foot, due to the pull of the tendo Achillis. 

Treatment.— The treatment consists of immobilization in a position 
of slight plantar flexion to relax the tendo Achillis. A light splint is 
sufficient for fixation, the patient being allowed to be up and about on 
crutches. The splint should be removed daily, after the third or fourth 
day, for massage and limited passive motion. After the fifth week, 
the splint may be removed and the foot used a little for walking. 
Loose fragments may cause severe pain and lameness. If they cause 
disability, they may be removed by operation, usually with excellent 
results. 

In fractures due to muscular action a fragment is broken from the 
posterior and superior portion of the bone corresponding to the inser- 
tion of the tendo Achillis. The displacement may be considerable, 
sometimes two or three inches or even more. In spite of this, the 
patient is usually able to walk slowly, if he is careful not to attempt to 
extend the foot (plantar flexion). The diagnosis is made easily by 
palpation of the loose fragment. 

The treatment consists of fixation of the ankle in extreme extension 
with early massage. After about five weeks the patient may attempt 
to walk, but he must be warned not to extend the foot forcibly for 
several weeks longer. The results of this plan are usually excellent, 
even when a considerable degree of separation exists. 

Operation, with suture of the fragment, may be indicated in some 
cases. When rapidity of healing is desirable and the surroundings are 
suitable for bone surgery, the operative treatment may be expected 
to give good results. 

Fracture of the Sustentaculum Tali.— Fracture of the sustentaculum 
tali is due to forcible inversion of the foot. Usually the external 
lateral ligament is torn completely through, and there is a permanent 
sinking of the inner border of the foot. The foot should be immobil- 
ized in slight inversion and extension (plantar flexion) to allow the 
union of the fragments, care being taken not to cause too great lengthen- 
ing of the external ligaments, if they have been torn. 

Fracture of the Scaphoid.— This has been shown by roentgen-rays 
to be a fairly common fracture. It is broken by compression of the 



FRACTURES OF THE METATARSALS AND PHALANGES 377 

bone between the head of astragalus and the cuneiform bones. The 
symptoms are prominence of the inner side and dorsum of the foot, 
and pain on direct pressure over the bone or by indirect pressure 
transmitted through the metatarsal bones. The patient is often able 
to walk, though with a noticeable limp. 

Treatment. —Treatment consists of reduction by direct pressure 
while the foot is held in forced abduction. In old cases with marked 
disability, operation with removal of the fragment may cause slight 
improvement. 

When the tubercle of the scaphoid has been fractured by muscular 
action, it should be treated by fixation in inversion. 

Fracture of the Cuboid and Cuneiforms.— There are no reported 
characteristic fractures of these bones. They may be broken by 
direct violence, either alone or as part of a general crushing injury to 
the foot. The treatment aims chiefly at the preservation of the plantar 
arch. 

FRACTURES OF THE METATARSALS AND PHALANGES. 

Fracture of the Metatarsals.— The bones are broken by direct injury, 
as from a weight falling upon the foot; or they may be broken by 
indirect injury in jumping, falls from a height, etc. 

Symptoms.— The symptoms are local tenderness and pain on pressing 
backward upon the corresponding toe. Crepitus and false point of 
motion may sometimes be obtained, especially in the first and fifth. 
There is usually very little displacement. 1 

Treatment.— In simple fracture a molded splint gives excellent 
support to the bones. The patient is kept on crutches for five or six 
weeks, after which the bones are supported by strapping with adhesive 
plaster. 

When there are abrasions on the dorsum of the foot, a suitable splint 
may be made by carving a firm wooden splint to the shape of the sole 
of the foot, and padding it to preserve the plantar arch. This is 
fastened on with adhesive strips and leaves the dorsum of the foot 
free for inspection and dressings. After the first week considerable 
weight may be borne on the foot, the patient walking on the splint as 
on a flat-soled shoe. 

In compound fracture it is better to dispense with all fixation 
apparatus, the gauze bandage giving sufficient support. If infection 
occurs and there is insufficient drainage, the pus is apt to burrow along 
the tendons and muscles on both the plantar and dorsal aspects of the 
foot. Necrosis of the bones, suppurative tenosynovitis, and general 
septicemia may follow. 

1 In a case seen recently there was a transverse fracture of the third, fourth, and fifth 
metatarsals near their base. There was considerable displacement upward and backward. 
Under anesthesia the surgeon forced the foot into a position of marked plantar flexion, 
and the assistant pressed the fractured bones into place by direct pressure. The bones 
slid back with a click, and there was no tendency to recurrence of the deformity. 



378 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

"When infection occurs, the foot should be incised so as to provide 
free drainage, counter openings being made on the sole or sides of the 
foot, if the necessity occurs. The dangers of infection in the foot are 
as great, or, possibly even greater, than in the hand. During the 
acute course of suppuration, the patient should be kept in bed with 
the foot at absolute rest. Once the spread of the infection is controlled, 
the prognosis depends largely upon the extent of bone involvement. 




Fig. 276. — Fracture of second, third, fourth, and fifth metatarsal bones. Heavy 
stone fell on foot. Age twenty-three years. (Ashhurst.) 



A rare injury which should be mentioned is fracture of the tip of the 
tarsal end of the fifth metatarsal bone, presumably by muscular action. 
No special form of treatment is required. 

Fracture of the Phalanges.— Direct violence accounts for the 
majority of fractures of the phalanges. The diagnosis is based upon 
false point of motion and crepitus, which are present in almost every 
case. 



MINOR DISLOCATIONS OF THE LOWER EXTREMITY 379 

Treatment.— If the fracture is recognized, there is no difficulty in the 
treatment, the aim being merely to prevent union in a deformed 
position. Metal plantar splints have been devised, having the shape 
of the foot, with a space for each toe. They are usually unnecessary, 
the same purpose being fulfilled by a heavy-soled shoe, the toes being 
kept in extension by adhesive straps. It is wise to have the top of 
the toe of the shoe entirely removed, so that there is no pressure upon 
the end of the toe, as dorsal angulation, which results in a condition 
similar to hammer-toe, is especially to be avoided. Wearing a suitable 
shoe of this type, the patient is able to be about during almost the 
entire period of healing. 

Fracture of the Sesamoid Bones.— The sesamoid bones of the great 
toe may be broken by a fall upon the ball of the foot. They usually 
require no special treatment, but occasionally the pain persists for 
several months or longer. In such cases, relief follows removal of the 
injured bone. 




Fig. 277. — Dislocation ot the hip, of three months' duration. No history of trauma. 
Treated for tuberculosis. Reduced under anesthetic ; return of function. 

MINOR DISLOCATIONS OF THE LOWER EXTREMITY. 

For the most part, dislocations of the lower extremity are serious 
accidents and require a considerable degree of surgical judgment, in 
order to secure successful results. In general, the dislocations of the 
lower extremity account for only 6 per cent of all dislocations. Those 
about the knee and ankle are likely to be associated with fracture and 
injury to the soft parts. Only the minor dislocations will be given in 
detail. 

Dislocation of the Patella.— The patella is dislocated by the contrac- 
tion of the strong quadriceps extensor group of muscles, or, in some 
cases, by direct violence. The ordinary dislocation is outward, and 
the displacement may be complete or incomplete. Apparently, the 



380 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

patella is forced up over the external condyle in such a way that the 
bone turns upon a longitudinal axis, the inner margin resting in the 
trochlear groove, with the articular surface directed more or less 
outward. If the dislocation is completed, the inner margin slips over 
the prominence of the external condyle. The bone may then be 
rotated, so that the articular surface is directed either externally 
posteriorly, or internally. The internal expansion of the quadriceps 
tendon is torn, but the tendon itself and the patella ligament are 
intact, and may be felt as firm bands beneath the skin. 

Chronic synovitis of the knee, which has caused a distention of the 
joint and the relaxation of the ligaments, acts as a predisposing cause. 
The direct cause is usually given as a sudden turn upon the knee, as 
in tennis or baseball, which causes a sharp pain and loss of power 
in the affected leg. Upon examination, the leg is found either extended 
or partially flexed, and motion of the joint is limited by pain. The 
bone is easily recognized as a hard mass beneath the skin, and the 
groove on the trochlea can be distinctly made out. The attached 
ligament and tendon are felt above and below the bone, while attempts 
actively to extend the leg are painful and ineffectual. 

Treatment. — The simplest method of treatment is reduction of the 
bone by direct pressure while the knee is passively extended, the hip 
being flexed in order to relax the rectus femoris and the patient being 
in a sitting position with the leg supported. It is necessary to recog- 
nize the position of the bone and to make it retrace the same steps 
which caused the dislocation. In complete dislocation outward, the 
first step is the manipulation of the inner margin of the patella over the 
prominent outer condyle of the femur, the bone being then rotated so 
as to bring the articular surface of the patella into the trochlea of the 
femur. If this maneuver is unsuccessful, the patella can sometimes be 
forced above the prominent ridge upon the outer condyle, entering the 
trochlea from above. Reduction has been accomplished in rare cases 
by extension, followed by forced flexion under an anesthetic. If 
operative interference is required, the following procedure may be 
tried. Sharp hooks are caught beneath the outer margin which is 
forcibly drawn forward, thus bringing about reduction. Where this 
fails, the case should be referred to major surgery. The after-treat- 
ment consists of treatment for the effusion into the joint and measures 
designed to allow the repair of the torn ligament. This remaining 
condition is essentially a sprain of the knee-joint and should be treated 
as such, either by fixation and massage, or by adhesive strapping. 
As there is considerable strain upon the joint, it is well to apply a 
support for six or eight weeks after the injury. When after-treatment 
is neglected, the accident is frequently followed by a tendency to 
recurrence. 

Inward dislocation, except in the incomplete form, is exceedingly 
rare. The incomplete dislocation, in w r hich the patella is found 
turned upon the longitudinal axis so that the articular surface looks 



MINOR DISLOCATIONS OF THE LOWER EXTREMITY 381 

directly inward, is more common. It is easily reduced by manipula- 
tion. 

Other forms of dislocation may occur when associated with rupture 
of the quadriceps tendon or ligamentum patellae. 

Old dislocations of the patella occasionally present themselves for 
treatment. Ordinarily, these patients have fairly good functional use 
of the leg. Unless there is marked disability, it is wiser not to advise 
operative attempts at reduction. The operative treatment for such 
cases consists of overlapping and suture of the relaxed lateral expan- 
sions of the quadriceps tendon. 

Dislocated Meniscus.— This injury is caused by a sudden rotation 
or flexion of the leg at the knee-joint. Often the movement causing 
the injury is apparently of only slight violence. 




Fig. 278. — Loose cartilage in joint; swelling disappears on extension. 

Diagnosis.— The diagnosis is made upon the characteristic locking 
of the joint, combined with tenderness over the torn coronary ligament. 
As the internal meniscus is the one usually displaced, the tenderness 
is located at the inner margin of the head of the tibia, usually nearer 
the anterior than the posterior end of the ligament. The injury is 
likely to be associated with synovitis of the knee-joint, and is apt to 
recur frequently. 

Treatment.— The treatment of the attack, when the joint is found 
locked, is passive extension of the knee, combined with direct pressure 
upon the meniscus, if it is found projecting. 

If the patient is seen at the time of the first dislocation of the menis- 
cus, the knee should be fixed with a posterior molded splint for eighteen 
to twenty days, and after this period, motion should be limited, either 
with an elastic knee-cap or adhesive strapping. Unless there has been 
considerable effusion into the .joint, the patient may be allowed to be up 



382 FRACTURES AND DISLOCATIONS OF LOWER EXTREMITY 

and about and to use the leg freely, except for the restriction exercised 
by the splint. 

Recurrent dislocation of the meniscus may be treated with an 
elastic bandage, worn continuously, which will in some cases prevent 
displacement. In some cases a leather knee-cap with a pad at the 
point of dislocation is required. Immobilization of the knee for a long 
period (six or eight weeks) with a circular plaster bandage has been 
tried as a curative measure ; it seems to diminish the tendency to recur- 
rence, but is rarely curative. 

If the above methods fail, operation, with the removal of the dis- 
located meniscus, may be advised. 

Dislocations of the Fibula.— Cases have been reported of dislocations 
of the upper and lower extremities of the fibula. They are so rare that 
their pathology and treatment are not clearly understood. Reduction 
by direct pressure and fixation for several weeks are the indicated forms 
of treatment. In involvement of the upper end, the knee should be 
flexed during reduction, in order to relax the biceps. 




Fig. 279. — Dorsal dislocation of the great toe. 



Dislocation of the Tarsus.— Dislocation of the tarsal bones is rare. 
They may be dislocated alone or in combination with the metatarsal 
bones. The subastragaloid dislocation of the ankle is the most 
important. The different varieties require different forms of treat- 
ment, based upon the character of the deformity. Operative inter- 
ference is often necessary. Injuries of this type are liable to be associ- 
ated with marked disability, which gradually clears up in several 
months, but seldom entirely disappears. 

Subluxation of the Fourth Metatarsal.— Due to improper shoes, the 
head of the metatarsal bone may be permanently displaced. This is 
seen in the severe types of metatarsalgia (Morton's disease). Treat- 
ment is by a brace to support the anterior arch and by properly fitting 



MINOR DISLOCATIONS OF THE LOWER EXTREMITY 



383 



shoes. In its most aggravated form, it may be necessary to remove the 
head of the metatarsal bone. 

Dislocation of the other metatarsals have been reported. They can 
generally be reduced by plantar flexion, traction and direct pressure. 

Dislocation of the Toes.— The great toe may be dislocated, usually 
backward and to the side. Such dislocations are often compound, the 
head of the metatarsal bones being forced through the skin. Reduc- 




Fig. 280. — Rentogenograph of mesial dislocation of the great toe. Closed reduction 
impossible owing to the position of the sesamoid bones. 



tion is by traction and direct pressure. If the tendon of the long 
flexor slips by the head of the metatarsal bone, reduction will be 
difficult or impossible, except by open operation. In some cases, it is 
necessary to excise the head of the metatarsal bone before reduction 
can be accomplished. 

Any of the other toes or the phalanges may be dislocated, either 
singly or in various combinations. The general principles of treatment 
are similar to those outlined under dislocation of the fingers. 



CHAPTER XIV. 
INJURIES TO THE LEG AND THIGH. 

HEMATOMA. 

Hematoma of the lower extremity may follow several different 
types of injury. The ordinary form follows contusion and is likely 
to occur in the thick muscular layers, either in the thigh or calf. In 
other cases the affection results from a sudden twisting or bending 
injury, such as is seen in sprain or muscle rupture, which causes lacera- 
tion of the small vessels and results in subcutaneous hemorrhage. 
Subperiosteal hematoma may result from contusion of the bone where 
it lies superficially. This form is frequently seen over the inner 
tuberosity of the tibia. In dislocation and fracture there is always 



i J 


W 

- wr 
i 





Fig. 281. — Subperiosteal hematoma of the left tibia in a case of hemophilia. Incised. 

considerable subcutaneous hemorrhage which, in rare cases, may result 
in hematoma. Because the leg is usually held in a dependent position, 
injuries are likely to be associated with a greater degree of bleeding 
than in the upper extremity or trunk. The diagnosis is made on the 
history and the presence of a fluctuating tumor with only insignificant 
evidences of inflammation. Except in the subperiosteal type, there is 
liable to be a large area of ecchymosis. Secondary infection is not 
uncommon. 

Treatment.— If seen in the early stages, that is, within the first few 
hours after the accident^ a firm bandage should be applied in order to, 



WOUNDS OF THE KNEE-JOINT 



385 



limit the subcutaneous hemorrhage. The hematoma is recognized 
as a slowly increasing, fluctuating swelling, and a pad made of felt 
or gauze, should be placed directly over the area of swelling and held 
firmly in place with a tight bandage. The leg should be placed at 
rest in a position of slight elevation. Care must be taken not to apply 
the bandage so tightly that the subsequent swelling will cause con- 
striction of the limb. We have found it convenient in some cases to 
apply a bandage tightly enough to stop bleeding and to leave this 
bandage in place for two or three hours, the patient being meantime 
under observation. The bandage is then removed and a second 
bandage applied, which is firm but less likely to constrict the leg than 
the first. The patient should be instructed to remove the bandage 
if the foot shows any of the signs which indicate that the blood supply- 
is being interfered with. 




Fig. 282. — Large hematoma of the thigh. 

A hematoma may, and frequently does, disappear rapidly. In 
some cases, however, it may persist for several days or weeks. It is 
the common experience that when a hematoma lasts for more than a 
few days, it is likely to persist for a long time, and this is particularly 
true in the leg and thigh. In the persistent cases, infection is almost 
certain to occur in the end ; therefore, it is the better practice to adopt 
operative measures as outlined elsewhere, if the tumor persists after the 
fifth or sixth day. 



WOUNDS OF THE KNEE-JOINT. 

Due possibly to its superficial location and special liability to trauma, 
the knee-joint is frequently injured by puncture or incised wounds. 
25 



386 



INJURIES TO THE LEG AND THIGH 



It has already been pointed out that penetrating injury to the cavity 
of a joint immediately takes on an increased significance due to the fact 
that the joint may become infected. The knee-joint, however, is of 
more importance than other joints, because infection, once it has been 
introduced into the joint, is eradicated only with the greatest difficulty. 
Infection of the knee-joint is generally considered one of the most 
serious types of local infection. 




Fig. 283. — Lacerations and destruction of tissues caused by a heavy rubber tire passing 

over the leg. 

If the wound penetrates the joint, the fact can usually be ascertained 
by inspection, which generally shows considerable clear serous, or 
serosanguineous discharge. As infection develops, there will be 
increased swelling, pain, and loss of function, associated with fever 
often up to 104° or higher. 




Fig. 284. — Same case as shown in Fig. 283. Leg practically healed after skin-grafting. 

Treatment.— When a wound of the knee-joint made with a clean 
instrument is seen early before infection is evident, two forms of 
treatment have been advised. Under the first plan, an incision is 
made at once as far as the joint capsule, and the wound packed so as 
to heal from the bottom. According to the second plan the surface 
of the wound is painted with iodine and the condition treated expec- 
tantly. The latter plan gives the best results in clean wounds; while 



INJURIES TO NERVES AND MUSCLES 387 

the former is to be preferred in wounds grossly infected. Especially 
in wounds of the knee, the character of the instrument should always 
be taken into consideration. A smooth, sharp instrument, such as a 
polished paper-knife, is much less likely to introduce infection, than is 
a rough instrument, such as a rusty nail or a pointed file. 

Given a case with beginning evidences of infection in the knee-joint, 
what treatment should be adopted ? Aspiration, with irrigation of the 
joint through the aspirating needle, has been advised; but, both 
experimentally and clinically, it has never yielded very satisfactory 
results. The solutions used have been, among many others— carbolic 
acid (2 per cent), alcohol (10 to 50 per cent), and dilute solutions of 
iodine (0.5 to 1 per cent). A far better plan is incision of the joint, 
with the thorough irrigation of the joint with saline followed by suture 
of the operative wound. The symptoms frequently subside rapidly 
following a single irrigation. In severe cases, where suppuration is 
clearly evident, large lateral incisions should be made and free drainage 
permitted. In cases of suppuration of the knee-joint, excellent results 
have followed the use of the Willems' treatment of free drainage and 
early active mobilization. 

In cases of infection about the knee-joint there is often a good deal 
of serous fluid which may, or may not, be purulent. It is often 
difficult as in cases of monarticular rheumatism to determine whether 
the contents of the synovial sac are purulent or simply serous exudate. 
Aspiration through an area of superficial cellulitis is almost certain to 
introduce infection into the joint, and it has consequently been our 
practice not to explore such cases, but to watch them carefully and to 
make the diagnosis for or against purulent inflammation without 
exploration of the joint. In case it is decided that there is pus in the 
joint, incision and irrigation are indicated. Where there is localized 
inflammation on one side of the leg, it is often safe to aspirate through 
a puncture made on the opposite side of the leg. 

INJURIES TO NERVES AND MUSCLES. 

Wounds of the leg and thigh may injure deep structures in the same 
manner as has been outlined under wounds of the arm. The wound 
should be carefully inspected for direct evidence of division of a tendon 
or nerve, and functional tests should be made to determine the presence 
of paralysis distal to the injured area. 

Symptoms.— The symptoms of nerve injury vary according to the 
nerve divided and the level at which the injury occurred. When a 
tendon is cut, there is corresponding loss of motion in the leg or foot. 
Space does not permit a complete description of all the various nerve 
or tendon injuries which may occur, but in general it should be noted 
that injuries about the thigh are likely to be associated with nerve 
injuries, while those in the lower third of the leg are more frequently 
complicated by injuries to the tendons, 



388 



INJURIES TO THE LEG AND THIGH 



Treatment.— The treatment of wounds of the tendons and nerves of 
the lower extremity is the same as of those occurring in the arm and 
hand. 




Fig. 285. — Spasticity of the lower extremities caused by traumatic hemorrhage into the 

cord. Recovery. 




Fig. 286. — Herpes following injury of 
the musculocutaneous nerve. 




Fig. 287. — Trophic ulcers. Hypopituitarism. 
Man, forty inches tall, aged fifty years. 



Rupture of the Plantaris Tendon.— Rupture of the plantaris tendon 
is. of fairly common occurrence in persons exercising violently, and is 
frequently seen in tennis players. The onset is acute, with sharp pain 



INJURIES TO NERVES AND MUSCLES 



389 



in the affected leg. Patients frequently assert that they were struck 
with a ball or stone, though when questioned, they admit that they 




Fig. 288. — Excessive growth of right leg, four and a half inches longer than mate, 
cause made out. Native of New York. 



No 



did not see the object which hit them. The pain and tenderness are 
referred to the region of the calf. After a few hours there is apt to be 
moderate swelling. Walking is usually possible, though painful. 

Treatment.— The treatment consists in 
rest for a few days, after which, the leg 
supported by adhesive straps and a band- 
age, walking may be permitted. As the 
function of the plantaris is practically nil, 
it is unnecessary to consider the repair of 
the torn tendon. 

Rupture of the Quadriceps.— Rupture 
of the quadriceps is caused by muscular 
action. 

Symptoms.— The symptoms are practi- 
cally identical with fracture of the patella, 
except that the patella can be felt uninjured 
and there is a deep groove above its upper 
margin. Disability is complete, both from 
loss of use of the tendon and from the asso- 
ciated effusion into the knee-joint. 

Treatment.— Conservative treatment will 
accomplish practically nothing where there 
is an appreciable degree of separation. 

Incision and suture of the tendon to the patella usually results in a 
complete and permanent cure. 

As the rupture almost certainly enters the knee-joint, the operation 




Fig. 289.— Rupture of the 
rectus femoris tendon. 



390 



INJURIES TO THE LEG AND THIGH 



should only be undertaken when the best surgical technic is available 
and in hospitals where all modern aseptic precautions may be observed. 
Much that has already been said in reference to fracture of the patella 
is referable equally to rupture of the quadriceps tendon, with the 
exception that in rupture of the tendon, because of the fact that there 
is usually considerable separation, conservative methods are ordinarily 
much less satisfactory than in the case of fracture of the patella. 

ACUTE SYNOVITIS OF THE KNEE. 

Serous synovitis of the knee may result from injury, or it may occur 
as part of general disease. The traumatic variety is the most common 
and is often associated with fracture or dislocation of the meniscus. 
A loose cartilage, a joint mouse, or a direct blow upon the knee, may 
act as the exciting cause. In many cases, the injury is caused by a 
twisting sprain of the knee, with or without evidence of tearing of the 
ligaments. 



IB S 

1 H . :HH 



Fig. 290. — Acute hemarthrosis of the right knee following trauma in a case of hemo- 
philia. Left knee has been operated for same condition. 

The typical history of an uncomplicated case is as follows: The 
patient remembers turning or twisting the knee, associated with sharp 
pain and more or less disability. After a few hours of comparative 
comfort, the knee gradually became more painful and the patient was 
unable to walk or bend the knee. In a few cases the history of an acute 
injury is absent, the affection apparently following a period of pro- 
longed exertion, such as mountain climbing, long-distance bicycle 
riding, etc. 

On examination, the knee is found in a partially flexed position and 
shows an enlargement which corresponds with the outline of the 
synovial cavity of the joint. Inasmuch as the cavity of the joint is 
greatest in the position of slight flexion, attempts at complete extension 
or flexion increase the joint-pressure and cause intense pain. 

The patella floats when the joint contains more than 30 cc of fluid. 
The knee-joint may, however, contain as much as 200 cc. Pressure 



CHRONIC SYNOVITIS OF THE KNEE 391 

of the knee-cap causes a distinct click when the floating patella strikes 
the trochlear surface. It must be remembered that the characteristic 
"patellar click" which occurs with a floating patella may be absent 
because there is insufficient fluid in the joint, because the knee is held 
in the flexed position, or because there is so much fluid in the joint 
that the patella cannot be pressed downward against the trochlear 
surface. 

Treatment.— During the acute stage, the patient should be put to 
bed with the knee supported in a semi-flexed position. An ice-cap 
should be applied and daily massage from below upward given to the 
entire limb. It may be necessary to give codein or similar drugs for 
the relief of pain. 

When the acute symptoms have subsided (after the fourth or fifth 
day in moderately severe cases) and the swelling has grown less, the 
absorption of the effusion may be aided by functional use of the leg 
with proper protection. Such protection may be supplied by a firm 
bandage or by adhesive strapping so applied as nearly to surround the 
knee, extending from the middle third of the leg well upward upon the 
thigh. The strips are placed obliquely around the knee, except for a 
narrow area about one inch in width in the popliteal space. A firm 
bandage is placed about this, and the patient is allowed to walk about 
on the affected leg, the adhesive plaster giving a fairly firm support 
and at the same time allowing a certain amount of motion which is 
sufficient to stimulate the circulation and promote absorption. Treat- 
ment is usually necessary for three weeks or longer. 

Another method of treatment which requires considerably more 
time but which is followed with equally good results, is the use of an 
elastic support made in the shape of a knee-cap which is removed daily 
to allow the massage of the entire leg. 

The application of splints, which are likely to act as a hindrance to 
the circulation, is usually unsatisfactory. If, after a reasonable period 
of rest, the effusion is still so great that the knee cannot be used without 
severe pain, the joint should be aspirated and the excess of fluid re- 
moved. Extreme care should be taken to prevent the introduction 
of infection during this operation. 

CHRONIC SYNOVITIS OF THE KNEE. 

Chronic effusion into the knee-joint may arise from the same 
causes as the acute. Bennett, 1 in an analysis of 750 cases, found the 
following to be the most common causes of effusion : 

1. Internal derangement of the joint 428 

2. Osteoarthritis 107 

3. Syphilis 42 

4. Rheumatism and gout 30 

5. Gonorrhea 28 

6. Loose bodies in the joint 24 

7. Miscellaneous 91 

1 New York Med. Jour., January 27, 1900. 



392 



INJURIES TO THE LEG AND THIGH 



In 56 out of the 91 miscellaneous cases, the cause could not be 
determined. The remaining 35 cases were due to hemophilia, diabetes, 
tuberculosis, nerve injuries, tabes dorsalis, etc. 

It has been our experience that since the Wassermann test has come 
into general use, syphilis has been found much more frequently than 
the above figures would indicate. In view of our present knowledge 
of infectious arthritis, it is probable that many cases would now be 
included under chronic infectious arthritis. 

In addition to the above, an interesting type of effusion in one or 
both knees has been described under the name of "quiet effusion," 
occurring in girls at the menstrual period and in older subjects at 
irregular intervals. It is apparently a vasomotor disturbance. 





Fig. 291. — Early Charcot's joint. 



Fig. 292. — Chronic gonorrheal arthritis. 



It has been claimed that tuberculosis may result in a tuberculous 
synovitis, with effusion into the joint, but without bone lesions or 
any other symptoms of tuberculosis. Such cases, if they exist, must 
be extremely rare. 

Treatment.— Syphilis is the most common specific type of infection 
which causes serous synovitis of the knee-joint. In the early stages, 
it is likely to be unilateral and is often not associated with other 
symptoms of syphilis, except a positive Wassermann test and the 
immediate improvement under antisyphilitic treatment. 

Many cases may be included under the term "infectious arthritis," 
and in such cases, it is important that the cause of the infection be 
located and removed, if possible. The teeth, the tonsils, the urethra, 
and the bladder are all common foci of infection. Having located the 
focus of infection it should receive appropriate treatment. Vaccine 
therapy, begun as soon as the causative organism can be located, may 
give relief in certain selected cases. 



CHRONIC SYNOVITIS OF THE KNEE 



393 



In the so-called "quiet effusion/' nitroglycerin, adrenalin, and thy- 
roid extract have all been recommended as beneficial. In patients 
who are markedly overweight, considerable relief can be secured by 
simple reduction in weight. 

In most cases of chronic synovitis local treatment of the knee is 
secondary to general treatment. The local application of counter- 
irritants, heat, and massage are all of sufficient value to justify their 
trial, but it is evident that a cure rests largely upon the course of the 
general disease. Where the swelling is marked, aspiration of the joint 
may become necessary, merely as a palliative measure for the relief of 
local symptoms. In general terms, the injection of any fluid into the 
joint for the control of the local condition is unjustified by the results 
obtained. 




Fig. 293. — Knee-joint laid open for severe 
streptococcus infection. Later suture of ten- 
don and aponeurosis gave good function and 
about 30 per cent of motion. 




Fig. 294.— Tuberculosis of the 
knee. Synovial type. 



In chronic cases secondary to trauma or internal derangement of the 
joint, counter-irritation with iodine or strong liniments is often followed 
by excellent results. Baking, massage, and the use of radiant light will 
aid in absorption of the effusion. Pressure with a firm bandage, or 
adhesive straps applied so as nearly to surround the joint, helps to 
increase the pressure in the synovial sac and thus to encourage absorp- 
tion of the fluid. It must be continued for a long period to accomplish 
lasting results. Occasionally a patient is seen who is obliged to wear 
an elastic knee-cap continuously in order to prevent recurrence. 
Aspiration at intervals of several weeks may be required in obstinate 
cases. In the cases associated with loose bodies or dislocation of the 
intra-articular fibrocartilage, operation should be advised. 



394 INJURIES TO THE LEG AND THIGH 

LOOSE BODIES IN THE KNEE. 

One or more loose bodies consisting of fragments of cartilage, bone, 
fibrin, and the like, may be found in the joint. These loose bodies 
are occasionally caught between the ends of the bone causing acute 
pain followed by symptoms of synovitis. The loose body is usually 
detected by the patient as a smooth, movable object beneath the skin. 
If the loose body is caught between the articular surfaces, there is a 
sudden acute pain and the patient falls to the ground. Ordinarily 
the symptoms of synovitis do not occur until a few hours after the 
accident. 

Treatment.— The loose body, if caught between the bones, can be 
dislodged by massage and passive motion of the joint. Following 
this, in most instances, an acute effusion results, which requires treat- 
ment as outlined above. After the first attack, the patient learns to 
relax the knee, which relieves the locking. As a palliative measure, 
support of the knee, either by an elastic bandage or by adhesive 
plaster strapping, may tend to prevent recurrence and to diminish the 
frequency of acute attacks, but it has no influence upon the causative 
factor. In chronic cases, the joint must be opened and the loose body 
removed— often several are found. 



PREPATELLAR BURSITIS. 

Following injury, the bursa in front of the knee may become enlarged 
and filled with fluid. The distended bursa is easily recognized as a 
fluctuating swelling on the anterior aspect of the patella, the swelling 
being limited to the extent of the bursa. 

A similar enlargement may follow continued irritation, such as occurs 
in long-continued kneeling, resulting in chronic bursitis. The condition 
is common in persons who work while kneeling, such as scrub women, 
floor polishers, etc., and is commonly known as ''housemaid's knee." 
While most of the weight in kneeling is borne upon the tuberosity of the 
tibia, scrub women and others who do similar work bring the weight 
upon the patella when reaching forward. 

Diagnosis.— It is comparatively easy to differentiate fluid in the 
prepatellar bursa from fluid in the knee. In bursitis the swelling is 
superficial and limited in extent, while in synovitis the swelling extends 
upward beneath the quadriceps muscle. The patellar click is, of course, 
absent in bursitis. 

The acute cases usually contain serous or serosanguineous fluid and 
subside in from three to six weeks. They may become chronic, and 
in such an event they are usually of very long duration and resistant 
to any form of treatment, except excision. They are rarely associated 
with pain or tenderness. In chronic cases, the walls of the sac become 
markedly thickened. 



PREPATELLAR BURSITIS 



395 



Treatment.— Acute bursitis should be treated by rest and the applica- 
tion of cold and pressure. Adhesive plaster, so applied as to make 
pressure upon the distended bursa, together with rest and the applica- 
tion of an ice-cap is an admirable plan of treatment. After the first 




Fig. 295. — Acute prepatellar bursitis, caused by a fall. 

week, if the swelling is not diminished in size, the bursa should be 
aspirated and firm pressure applied by means of adhesive-plaster straps. 
The aspiration should be repeated every four or five days. If the fluid 
tends to recur rapidly, absorption may be hastened by the injection of 
50 per cent alcohol (1 to 5 cc) or 95 per cent carbolic acid (10 to 20 
drops) or Murphy's solution. The idea of the injection is to secure 




Fig. 296. — Chronic prepatellar bursitis in a hardwood-floor layer. 

irritation of the internal surface of the sac and thus to hasten absorp- 
tion and adhesive obliteration of the sac. 

In chronic bursitis, little can be gained by the ordinary simple 
methods. Rest and pressure, with aspiration of the bursa, are sue- 



396 



INJURIES TO THE LEG AND THIGH 



cessful in only a few cases. Injection of the bursa with irritants as 
outlined above may be tried, but because the walls of the bursa are 
chronically thickened, considerable swelling will remain even when the 
fluid has been entirely absorbed. Complete excision of the bursa is 
a much better form of treatment. If local anesthesia is used, care 
should be taken to inject carefully and close to the bone around the 
entire bursa, for the deep surface of the bursa is nearly always adherent 
to the bone, and unless the injection is carefully made the removal will 
be extremely painful. The wound should be closed with silk sutures, 
without drainage. 

SUPPURATIVE BURSITIS. 




This affection may follow acute or chronic bursitis. Infection may 
gain access to the bursa from the blood stream, or, what is more 

common, from a small scratch or abra- 
sion of the overlying skin. It may be, 
and probably frequently is, introduced 
by means of puncture in the careless 
use of the aspirating needle. As the 
contents of the bursa serve as an ex- 
cellent culture medium, great care 
should be taken to preserve the strictest 
asepsis during aspiration of a bursal sac. 
Symptoms.— The onset is accompa- 
nied by an increase in the general and 
local symptoms, which may occur 
suddenly or gradually. The bursa 
becomes tense and painful and the 
surface shows redness and increased 
local heat. The surrounding edema 
is more marked than in simple bursitis, 
and there may be localized induration 
in the surrounding tissues. 
Suppurative bursitis may also follow a penetrating wound of the 
bursa. The discharge of a considerable quantity of serosanguineous 
or seropurulent fluid from a wound over the knee-cap is usually due to 
an injury of either the bursa or the joint-cavity. In the absence of 
joint symptoms, the diagnosis of penetrating wound of the bursa may 
be made in cases showing this symptoms. If the discharge, previously 
serous in character, becomes purulent and local inflammatory symp- 
toms occur, suppurative bursitis has occurred. 

Treatment. — Suppuration of the bursa should be treated by wide 
incision in the long axis of the leg. The cavity should be packed with 
gauze so that the walls of the bursa are held widely apart. A con- 
tinuous wet dressing may be applied during the acute stage. Occa- 
sionally this results in healing. More frequently, the wound grows 



Fig. 297. — Acute subpatellar bur- 
sitis, swelling appearing at both 
sides of the patellar tendon follow- 
ing a fall. 



SUPPURATIVE BURSITIS 397 

gradually smaller but the discharge persists, and if the sinus closes 
completely, the inflammatory symptoms recur. In such cases, the 
bursa should be completely excised. These cases are very stubborn 
to treatment and the prognosis should be guarded. Symptoms fre- 
quently persist for months, even after complete excision of the sac. 

Wounds of the bursa when seen early should be cleansed thoroughly, 
painted with iodine solution, and sutured. If a sinus is allowed to 
persist, the constant moistening of the dressing with the profuse 
serous discharge is almost certain to result in infection. When infec- 
tion occurs in spite of this treatment, or if the wound is infected when 
first seen, the bursa should be freely opened and the treatment con- 
tinued as outlined above. 

Other Varieties of Bursitis.— Any one of the bursa? about the leg 
and thigh is subject to the same forms of bursitis as is the patellar 
bursa, but they occur much less frequently. The most frequent 
varieties are pretibial bursitis, sub gluteal bursitis, and bursitis of the 
bursa under the tendon of the semimembranosus. 

In pretibial bursitis, the bursa beneath the ligamentum patellae 
or of the one between the tibial tubercle and the skin may be involved. 
These bursse frequently communicate with the joint. 

The bursa beneath the gluteus maximus muscle is subject to inflam- 
mation. The diagnosis rests upon local tenderness, associated with 
slight swelling. Internal rotation of the thigh is usually painful. 

Inflammation of the bursa beneath the semimembranosus is made 
evident by slight swelling and tenderness at the upper part of the 
popliteal space. Extension of the leg is accompanied by increased 
tension in this bursa; consequently, the leg is usually held in a position 
of partial flexion. This bursa not uncommonly communicates with the 
knee-joint. 

The bursse under the heads of the gastrocnemius muscle or beneath 
the tendon of the popliteus are in close relation to the knee-joint. 
They may become inflamed and give symptoms of pain and disability. 
There is usually tenderness over the region of the bursa. 

In the dissecting room several cases of bursitis of the bursa beneath 
the tendon of the obturator internus muscle have been noted. This 
is ordinarily associated with thickening of the walls of the sac, erosion 
and roughening of the cartilage lining the groove where the obturator 
internus tendon passes over the floor of the lesser sciatic notch. In 
one case seen recently, inflammation of this bursa was diagnosed 
because of the typical symptoms when the muscle was thrown into 
action and because of tenderness over the course of the tendon on 
digital examination per rectum. The diagnosis was confirmed by the 
roentgenograph, which showed roughness of the floor of the lesser 
sciatic notch. 

The treatment of these different types of bursitis, as well as of any 
of the even less frequent varieties which may occasionally occur, is 
carried out on the same general plan as has been noted under pre- 



398 INJURIES TO THE LEG AND THIGH 

patellar bursitis. In all persistent cases, excision is the treatment 
indicated. Except as a result of penetrating wounds, suppuration 
is rare in the more deeply situated bursa?. 



SPRAIN. 

The general symptomatology and treatment of sprains have already 
been discussed and should be referred to in reference to treatment of 
any particular sprain. Sprains are especially likely to occur in the 
lower extremity, frequently in the ankle and less often in the knee and 
hip. Attention is directed to the importance of differentiating between 
sprain and linear fracture or sprain-fracture. 

Sprained Ankle.— The point of tenderness is usually located over 
the external lateral ligament just below the external malleolus. 1 

Symptoms.— The ordinary history of sprained ankle is that there is 
a period following the injury during which the patient is able to walk 
with only slight pain. Later, the pain becomes severe, every attempt 
to use the foot being associated with acute pain. Swelling, beginning 
near the external malleolus, may involve the entire region of the 
ankle. In case of doubt a roentgen-ray examination should be made to 
exclude fracture. 

Treatment.— In this form of sprain, an adhesive-plaster dressing 
applied according to the method of Gibney is most satisfactory. After 
the leg has been shaved, washed with soap and water, and rinsed with 
alcohol, the adhesive strapping is applied so as to furnish a firm support 
for the entire ankle except a narrow strip anteriorly. 

For the application of the strapping, the foot is held at a right angle 
and a long strip of adhesive plaster about 1 \ inches wide is applied like 
a stirrup, extending from the upper third of the leg on the inner side 
downward beneath the sole of the foot and upward on the outer side 
of the leg to the same level as the starting point. A second strip 
similar to this is applied, overlapping the first strip about one-half. 
A narrow strip about 1 inch in width is then applied parallel to the 
sole of the foot beginning near the first metatarsophalangeal joint 
and extending backward around the heel to the fifth metatarsophalan- 
geal joint. A vertical strip is then placed anterior to the two long 
strips, but extending only about 2 inches above the ankle-joint. 
The strips are now applied alternately in the long axis of the leg and at 
right angles to it until the foot and ankle are entirely covered, except 
the narrow strip along the front, which is left uncovered to allow for 
swelling. This space should always be preserved in order to prevent 
constriction in case the foot swells after the strapping has been applied. 
The patient may be allowed to walk at once. 

After a severe sprain of the ankle, the support should be worn for 

1 Sprain with injury to the internal lateral ligament of the joint may occur, but it is 
quite rare. 



SPRAIN 399 

at least three weeks, the strapping being removed and reapplied every 
seven or eight days. The ankle should be supported with snug-fitting 
lace shoes for two or three months. 

Sprain of the Knee.— In addition to the ordinary symptoms, sprain 
of the knee may be associated with abnormal mobility if the lateral 
ligaments are torn. Besides the symptoms of sprain, there is almost 
always an effusion into the knee-joint, in which event the sprain be- 
comes a case of acute traumatic synovitis. 

Treatment.— The treatment consists of measures for the cure of the 
traumatic synovitis, combined with support of the injured ligament. 
Adhesive-plaster strapping or a leather knee brace may be applied, 
as measures for support. Restoration of function may be hastened 
by proper massage and counter-irritation. Very rarely it may be 
necessary to suture the lateral ligaments in order to prevent lateral 
mobility of the knee-joint. 

Sprain of the Hip.— Because the hip is thickly covered with muscles, 
direct examination is difficult. Lameness and pain on motion are the 
ordinary symptoms of sprained hip. It is most important to exclude 
fracture in injuries about the hip. For this reason it is advisable to 
have a roentgen ray in every case. 

Treatment.— Rest and massage, with early functional use, briefly 
outline the treatment of sprained hip. If the condition persists for 
more than a few weeks, there is probably an undetected fracture or 
disease of the joint. In children, a persistent "sprained hip" usually 
indicates tuberculosis. 



CHAPTER XV. 
MISCELLANEOUS AFFECTIONS OF THE LEG AND THIGH. 

CELLULITIS. 

When cellulitis occurs in the lower extremity, it is apt to be accom- 
panied by more swelling and edema than in other parts of the body, 
because the circulation is less active. For this reason, in cases of severe 
cellulitis of the leg it is wise to insist on rest in bed with the leg slightly 
elevated, especially in patients past mid-life. Otherwise, the treat- 
ment is the same as described elsewhere for cellulitis. 

LYMPHADENITIS. 

Bubo.— Enlargement of the inguinal chain of glands is called bubo. 
This may be caused by pyogenic infection of the leg or of the external 
genitals. In leg infections the glands about the saphenous opening 
are more apt to be involved than are those in the inguinal region, but 
the infection in some cases jumps the first group of glands and causes 
inguinal bubo. Not infrequently abscess formation may occur without 
any evident point of infection either on the genitalia or lower extremity. 
It is possible that in such cases the infective organism has been intro- 
duced through a small abrasion on the leg or foot some weeks pre- 
viously, and that, while the original focus has healed, the infection has 
remained semi-dormant in the inguinal glands. Bubo occurs almost 
constantly with chancre of the external genitalia but rarely goes on to 
abscess formation. With chancroid the enlargement is less frequent, 
but when it occurs abscess formation is common. Tuberculous bubo 
is occasionally seen, but it is comparatively much less common than 
other forms of infection. Gonorrheal bubo is frequently seen in un- 
treated urethritis or in patients who are careless as regards personal 
cleanliness. Enlargement of the inguinal glands may be associated 
with carcinoma, Hodgkin's disease, lymphosarcoma, bubonic plague, 
and some other conditions. 

Symptoms.— The symptoms of bubo begin with swelling in the groin. 
At first the enlarged nodes are discrete tumors easily palpable and only 
slightly painful. In tuberculosis and syphilis this stage is very long- 
drawn out, covering months or longer, and abscess formation, unless 
due to mixed infection, is not apt to occur. In septic infection the 
glands slowly enlarge and become confluent. When this stage is 
reached they become attached to the skin and deeper parts. After 
a period varying from a few days to several weeks the skin over the 



LYMPHADENITIS 



401 



glands becomes reddened, tenderness increases, and there is evidence 
of abscess formation. The mass of glands is felt in the groin as an 
enlongated tumor three or four inches in length and about two inches 
in width. There may be considerable induration of the surrounding 
subcutaneous tissue and skin. The disability due to the mass in the 
groin and the associated tenderness causes the patient to walk with a 
limp, or in severe cases may confine him to bed. 

Diagnosis.— Bubo must be differentiated from abscess secondary to 
sacro-iliac disease or vertebral caries, which may track forward and 
point in the groin in such a manner as to resemble bubo on superficial 
examination. 

Treatment. —The treatment of acute bubo during the early stages 
consists in rest with the application of an ice-cap or the use of ichthyol 
ointment (20 to 50 per cent). The point of entrance of the infection 
should be carefully searched for ; if found, it should receive appropriate 
treatment. A large number of early buboes will subside under this 




Fig. 298. — Large popliteal abscess from an ulcer on the leg. 

form of treatment, but if the glands are matted together and attached 
to the skin, operation is almost certain to be required. As the develop- 
ment of a glandular abscess is very slow, it is generally safe to wait for 
localization. If the surrounding area of edema and induration is slowly 
decreasing and if the general symptoms are becoming less severe, the 
glands may be poulticed and the case treated conservatively until the 
pus becomes localized and there is evident abscess formation ; but if the 
area of inflammation is steadily increasing or if the general symptoms 
are severe, incision should be made at once. The incision is made 
obliquely, parallel to the crease of the groin, and in most of these cases 
need not be very large. In some buboes there may be two or more 
distinct areas of softening, in which event incisions should be made at 
each point. The wound is dressed with iodoform gauze or with an 
antiseptic ointment, and cleansed daily either with saline or a mild 
antiseptic solution. Healing is very slow, suppuration sometimes 
lasting for several weeks or longer. During the later stages radiant 
heat or the use of direct sunlight will often cause rapid improvement. 
26 



402 MISCELLANEOUS AFFECTIONS OF THE LEG AND THIGH 



Syphilis of the glands is seldom acute and rarely requires operation. 

The glands subside with the healing of the chancre under general 

anti syphilitic treatment. Tuberculous bubo should be excised en 

masse. 
Abscess of the Popliteal Space.— Abscess of the popliteal space may 

occur from suppuration of the popliteal lymph nodes or be secondary 

to an infectious process in the neighboring bursa? 
or bone. The symptoms are pain, swelling, in- 
ability to extend the knee, and edema of the leg. 
The pulsation of the popliteal artery may be 
transmitted to the mass but it is not expansile 
as in popliteal aneurysm. The abscess should 
be incised early, for if neglected it may involve 
the popliteal artery or break into the knee-joint. 
In making the incision, care should be taken not 
to injure the artery or the popliteal nerves. 

VARICOSE VEINS. 

Varicose enlargement of the veins of one or 
both legs is a very common affection. Varicose 
veins are found in patients who are obliged 
to stand on their feet a great deal and are more 
common in women than in men, occurring most 
frequently after mid-life. When small, they 
cause no pain or discomfort, and consequently 
they rarely come to the notice of the surgeon 
before they are markedly enlarged. Patients 
ordinarily present themselves for one of the fol- 
lowing reasons : Chronic ulceration of the affected 
leg; discomfort and heaviness of the leg; hemor- 
rhage from a ruptured vein; thrombosis and phle- 
bitis of the veins; edema of the leg. 

Treatment. —The palliative treatment consists 
in the application of an elastic bandage or stock- 
ing which supports the veins. It must be worn 
daily, and while it relieves the symptoms it 
rarely, if ever, results in cure. The chief value 
of this plan lies in the relief from discomfort 
and the fact that it prevents the occurrence of 
complications such as thrombosis, phlebitis, rup- 
ture, etc. A much better method of treatment 
consists in complete excision of the dilated veins. 
This operation is best performed under general anesthesia, because sev er al 
incisions are usually required at different locations in the leg. It is 
better to excise the veins by several incisions rather than by one long 
incision along the entire length of the vein. If the vein is carefully 




Fig. 299. — Varicose 
veins in a girl, aged 
twelve years, with vari- 
cosities of the vulva and 
gluteal re g i o n. No 
cause made out. 



VARICOSE VEINS 



403 



dissected out and cut and ligated at one place, it will be possible to 

pull the cut end through to a second incision made an inch or two from 

the first. In this way the entire vein may be removed. It must be 

remembered that the vein, although plainly evident when the patient 

is standing, empties itself when the patient is placed horizontally on the 

operating table. Consequently the 

veins should be marked out on the 

skin with silver nitrate, or some 

other form of indelible marking, 

before the anesthetic is given. 

After the veins have been removed, 

the wounds are sutured with fine 

silk and the patient is kept in bed 

for about ten days. 

In suitable cases, where only one 
vein is dilated, a small incision is 
made at the highest point of dila- 
tation and the vein divided after 
preliminary double ligation. In 
the case of the internal saphenous 
vein the operation is done high up 
on the thigh near the saphenous 
opening. The wound is closed with 
silk and the patient allowed to be 
up and about. The following test 
may be applied before operating 
to determine if this simple divi- 
sion and ligation will be sufficient : 

The patient is placed in the horizontal position and the leg is elevated 
until the veins are nearly emptied. Pressure is made over the vein 
near the saphenous opening, and while this pressure is maintained, the 
patient stands erect. If the dilated veins do not become distended, it 
is evident that simple division and ligation is all that is required. 




Fig. 300. — Large varicosities of the 
internal saphenous vein. 




Fig. 301. — Mayo's varicose vein enucleator. 



If carefully chosen cases a modification of this method, which 
consists in multiple division and ligation, will be found of value. 

When a single large vein is involved, Mayo's blunt dissection method 
has been found of value. He makes a small incision and threads one 
end of the vein through the ring of a special dissector. This is a long 
instrument somewhat the shape of an applicator, except that the end 



404 MISCELLANEOUS AFFECTIONS OF THE LEG AND THIGH 

is formed in the shape of a small ring about 1 cm. in diameter. The 
ring-shaped end is placed at right angles to the handle, the result 
being that the ring can be forced along the course of the vein, tearing 
away any small tributary veins and completely separating the vein 
from the surrounding tissues. When this has been continued as far as 
practicable, a second incision is made where the end of the instrument 
can be felt beneath the skin, and the vein is ligated and divided at this 
point. The loosened portion of the vein can be drawn out from 
beneath the skin. Surprisingly little hemorrhage follows this opera- 
tion. The small side branches which are torn off rarely bleed appreci- 
ably. In the same manner, the instrument may be passed further 
along the vein and the process repeated. 

In cases where the deep veins are chiefly involved, it is unnecessary 
to remove the superficial veins. Good results may be obtained if the 
points of communication (usually from three to six) between the deep 
and superficial veins are searched for and ligated . These points are easily 
found, as they are indicated by the points of greatest venous distention 
and tortuosity. A special test for these points is made with a ring 
about two inches in diameter. This ring is pressed against the leg 
over the suspected veins, and if the deep veins are at fault, the veins 
included in the ring will be seen to fill when the patient stands erect. 
This point is marked, and at operation an incision is made down to the 
muscle in front of the group of dilated veins. The deep fascia is 
raised until the connecting branch is seen and ligated. In the same 
manner all the connections between the deep and superficial veins 
may be obliterated. This operation may be performed under local 
anesthesia. 

In any case of varicose veins, the decision as to the best plan of 
treatment depends largely on the extent and location of the veins 
involved . 

PHLEBITIS AND THROMBOSIS. 

From a clinical standpoint there are three kinds of phlebitis occurring 
in the veins of the lower extremity which may come under the observa- 
tion of the surgeon. As phlebitis and thrombosis are commonly 
associated, they are usually discussed together, the term phlebitis 
being understood to include thrombosis. 

Postoperative Phlebitis.— This affection usually begins either in the 
femoral or saphenous veins about the tenth or twelfth day after an 
operation, usually a laparotomy, and is associated with pain and edema 
of the affected leg. There is a febrile movement during the acute stage 
which may last for a week or longer and the temperature may rise as 
high as 102° F. Suppuration is rare. A similar phlebitis may occur 
after parturition, or after an acute infectious disease, such as typhoid 
or pneumonia. The swelling of the leg may persist for months or 
years. 



PHLEBITIS AND THROMBOSIS 



405 




Fig. 302.— Marked edema of the leg of two days duration. Acute phlebitis. 





Fig. 303.— Marked thrombosis of 
the veins above a chronic ulcer. 



Fig. 304.— Old chronic ulcer of the 
leg, showing shortening of the extensor 
group. 



406 MISCELLANEOUS AFFECTIONS OF THE LEG AND THIGH 

Postoperative phlebitis is now less common than when patients were 
kept for a long period after an operation flat on their backs with their 
legs extended so that the femoral vein was dragged upon and pressed 
against the pubic ramus. Now, after operations the thighs are kept 
semi-flexed and patients are allowed to move about freely in bed. 
This treatment prevents pressure and strain and keeps the blood 
circulating. 

Treatment.— During the acute stage, the patient should be kept in 
bed with the leg elevated and an ice-cap applied to the area of tender- 
ness. After a week or ten days the patient may be allowed to walk 
a little, if the affection has been of mild degree. During the stage of 
decline, counter-irritation and support with a firm bandage are of 
value. Massage should not be used for the first few weeks, because 
of the danger of pulmonary embolism following the breaking off of a 
large thrombus. Later, in case of persistent edema of the leg, baking 
and passive and active movements, massage, and support with an 
elastic stocking are all beneficial, but the patient should be warned 
that progress is usually very slow. 

Phlebitis of Varicose Veins.— This is the most common form of 
phlebitis. In cases of varicose ulcers of the leg there is almost con- 
stantly an area in the immediate vicinity of the ulcer in which the veins 
are more or less inflamed and may be felt as tender, indurated cords 
beneath the skin. Even when there is no wound of the skin, phlebitis 
may follow a blow or other injury, or it may occur apparently without 
cause. Edema is common but usually slight in extent. In many cases 
the lesion begins as a paraphlebitis and is caused by infection brought 
from some distance (infected blister on the foot, infection about the 
toenail, etc.) by the lymphatics which lie in close proximity to the 
veins. It is probable that as the microorganisms are carried along 
the lymphatics, pressure or trauma causes a localization of the infection 
which spreads secondarily to the vein. The inflammation usually 
assumes a chronic character and comparatively seldom causes active 
suppuration. 

Treatment. —Severe cases should be confined to bed with an ice-cap 
applied to the area of phlebitis. Later, ichthyol ointment should be 
applied and the patient allowed to be up and about. Although the 
indurated vein may be felt for several months, the acute symptoms 
usually disappear in a few weeks. 

In mild cases occurring in the neighborhood of a varicose ulcer, it is 
usually unnecessary to send the patient to bed. Ichthyol may be 
applied and the leg bandaged so as to give firm support. The indurated 
veins usually disappear long before the ulcer is healed. 

Localized Phlebitis.— In a certain number of cases localized phlebitis 
occurs in what apparently has been a perfectly healthy vein. There is 
no varicosity, no injury, and it is clinically unlike the postoperative 
type of phlebitis. Usually only a small part of a superficial vein is 
involved. This classification would include gouty phlebitis and certain 



CHRONIC ULCER OF THE LEGS 



407 



other types of obscure origin. Possibly some of the cases are due to 
infection of the vein through a minute wound, or from a continued local 
irritation such as the rubbing of a vein by a tight boot. It frequently 
starts as a paraphlebitis, as described above. 

Treatment.— If any constitutional condition be made out which might 
be the cause, treatment should be directed toward the cure of the 
general disease. In one patient who had recurrent attacks, the 
diagnosis of gout was made. Colchicum caused the phlebitis to 
disappear in forty-eight hours. 

In most cases we are limited to local measures, such as ichthyol 
ointment, local heat, etc. As there is little or no associated swelling 
of the leg, there is only slight disability. Consequently, the patient 
may be allowed to be up and about. If the phlebitis shows a steady 
tendency to advance, operation may be required. However, operation 
is rarely or never justified, cure under conservative treatment usually 
being complete in from three to four weeks. 





Fig. 305. — Syphilitic ulcer of the leg in 
a child. Note profuse discharge. 



Fig. 306. — Varicose ulcer. 



CHRONIC ULCER OF THE LEGS. 

Among hospital and dispensary patients this is one of the most 
common affections which require surgical care. The typical cases 
are seen in people past mid-life, who are obliged to stand on their feet 
many hours during the day, and in people who are overweight. Any 



408 MISCELLANEOUS AFFECTIONS OF THE LEG AND THIGH 

of the factors which act as a hindrance to circulation or cause chronic 
congestion predispose to ulcer of the leg. The most common local 
causes are varicose or thrombosed veins, eczema, obesity, exposure to 
cold and wet, constriction of the leg by tight garters, inflammatory 
conditions such as dermatitis, etc. Local infection may cause the 
persistence of an ulcer which otherwise would heal kindly. Often a 
slight scratch in a patient predisposed to ulcer causes excessive ulcera- 
tion, if it chances to become infected. 





Fig. 307. — Ulcer of sixteen years' 
duration in a young man, the re- 
sult of firecracker burn at the age 
of three years. Never healed. 
Cured by skin-grafting. 



Fig. 308. — Pressure necrosis of the dorsum 
of the foot from adhesive strip extension in 
compound fracture of the tibia. 



Of the general causes of ulcer, syphilis is the most common. Syphi- 
litic ulcers have a characteristic punched-out appearance and are apt 
to occur in young adults. It is a clinical fact that ulcers located above 
the mid-point of the tibia are apt to be syphilitic while ulcers below this 
point are usually due to varicose veins. A positive Wassermann test 
is confirmatory. Other general diseases such as diabetes, arterio- 
sclerosis, and anemia may predispose to chronic leg ulcer. Cardiac and 
renal diseases cause edema, and this in turn acts as a local hindrance 
to adequate circulation, diminishing the resistance of the tissues. 

The exciting cause of the ulcer is usually a traumatism of some sort. 
The leg suffers a slight injury, such as an abrasion or a scratch which 
refuses to heal, finally becomes infected and a chronic ulcer results. 
Local infection also plays a distinct role, ulceration following infected 
wounds much more frequently than it does clean wounds. When 
fully developed an ulcer may show simply a small excavation in the 



CHRONIC ULCER OF THE LEGS 



409 



center of an area of induration, or a large deep cavity several inches 
in diameter and nearly an inch in depth. Fully-developed ulcers are 
apt to show mixed infection, strepto- and staphylococci predominating. 
Smear from the discharge often show innumerable varieties of micro- 
organisms. 

Treatment.— Prophylaxis consists in the most careful attention to 
every wound and injury to the leg in persons who might be predisposed 
to ulcer. For practical purposes, this includes every one past mid- 
life. Every wound in a patient past mid-life should be regarded as a 
possible ulcer and treated accordingly. There are two points which 
have already been noted : (1) That ulcers result from poor circulation; 
(2) that infection encourages ulcer formation. Consequently, the 
wound should be carefully sterilized with 
tincture of iodine (one-half strength) and 
covered with a dry dressing. If infection 
does not develop, the wound will probably 
close without ulcer formation; but if infection 
supervenes, ulceration is almost sure to follow. 
Ointments and wet dressings, because they 
keep the wound open and thus predispose to 
local infection, are contraindicated. During 
the healing, the circulation may be improved 
by rest in bed with the leg elevated. 

General Treatment.— -In syphilitic cases the 
general antisyphilitic treatment is indicated. 
If diabetes, or anemia, or any other general 
disease is present, appropriate treatment 
should be instituted. Even in cases in which 
no general disease is found, careful attention 
to the diet and general health will show results 
in the improvement of the local condition. 

Treatment by Rest in Bed.— Because most 
ulcers are secondary to a condition of insuffi- 
cient circulation in the leg, almost every 
case will be improved by rest in bed. It 

has been the custom, whenever possible, to make every case of chronic 
ulcer of the leg a bed-case, keeping the patient constantly in the hori- 
zontal position with the leg slightly elevated on pillows. When there 
is any tendency to cellulitis, the treatment is begun by the applica- 
tion of a continuous wet boric acid (2 per cent) dressing. When the 
inflammatory reaction has disappeared, the various applications men- 
tioned below may be useful. 

Ambulatory Treatment.— -For economic reasons many patients are 
unwilling to remain in bed during healing, and for such, some form of 
ambulatory treatment must be devised. It is impossible to outline a 
definite routine of treatment which would be applicable to all cases. 
In the first place, it is necessary to overcome the acute symptoms of 




Fig. 309.— Old syphilitic 
ulcer of the leg undergoing 
malignant degeneration. 



410 MISCELLANEOUS AFFECTIONS OF THE LEG AND THIGH 

pain and swelling and this is usually accomplished by a wet dressing 
of mild antiseptic solution, such as boric acid or aluminum acetate. 

The leg and ulcer should be well cleansed daily with soap and water, 
except the eczematous cases which may be cleansed with oil. After 
cleansing, it is necessary to decide the method of application best 
adapted to the healing of the particular ulcer. In all cases, the attempt 
is first made to remove the superficial slough and to have the ulcer 
take on the healthy appearance of a healing wound. This may be 
accomplished by the application of the continuous wet dressings above 
mentioned, by the application of mild antiseptic ointments, such as 
boric acid ointment or weak mercurial ointments. Ichthyol ointment 
(10 to 20 per cent) gives most favorable results in some cases. 




Fig. 310. — Strapping a leg ulcer. (Ashhurst.) 

In all cases not confined to bed, the use of some method of support 
for the circulation is essential. When a wet dressing is used, a firm 
gauze bandage is applied, including the foot and extending over the 
calf. When ointments or other local applications are used, a muslin 
bandage may be more advantageous. It is firmly applied from the 
metatarsal region of the foot to a point above the calf, so as to offer 
support to the vessels of the leg. This bandage must be carefully 
applied, so as to fit the leg snugly at all parts. A firm bandage, well 
applied, will in itself accomplish much more than any form of local 
application; and a bandage, poorly applied, will sometimes undo the 
good results of several weeks of treatment. This bandage should be 
changed daily by the surgeon and never removed by the patient. After 



CHRONIC ULCER OF THE LEGS 



411 



the ulcer heals, the patient may be given an elastic bandage or an 
elastic stocking which he may apply himself. 

After the acute inflammation has subsided, the local treatment 
should be changed to stimulative applications, such as balsam of Peru, 
red wash, scarlet red, tincture of iodine (1 per cent), etc. A most useful 
application is a mixture of one part of tincture of iodine and nine parts 
of glycerin. At times, silver nitrate should be used for the cauteriza- 
tion of exuberant granulations. Each individual case requires its 
own particular treatment. One case, which had been under treatment 
for months and in which the leg showed a number of small strepto- 
coccus pustules in addition to the ulcer, healed after the entire leg had 
been well scrubbed with a brush and tincture of green soap and the 
application of a 10 per cent ammoniated mercury ointment. Cases 




Fig. 311. — Pseudo-elephantiasis resulting from chronic varicose ulcers. 



showing eczema should be treated with zinc oxide, and syphilitic cases 
should be dressed with mercurial ointment. It should be remembered, 
however, that often the ordinary ulcer will heal under local treatment 
with blue ointment. Indeed we have found the official unguentum 
hydrargyri, diluted with four -parts of vaseline, a most satisfactory 
ointment for many leg ulcers. The healing of an ulcer after the use 
of mercury has, therefore, no diagnostic significance. 

Local pressure upon the ulcer can be secured by adhesive straps. 
This method is applicable to healing ulcers during the late stages when 
they show little or no discharge. After cleansing the ulcer and the leg, 
a little powdered boric acid is dusted over the surface of the ulcer and 
the ulcer entirely covered by narrow overlapping strips of adhesive 
plaster extending two-third around the leg. This seems to hold the 
advancing edge of the epithelium firmly against the granulating 



412 MISCELLANEOUS AFFECTIONS OF THE LEG AND THIGH 

surface of the ulcer and thus to aid epithelization. In suitable cases 
healing will advance rapidly under this dressing. 

In recurrent ulcers healing is stimulated and the scar strengthened 
by the application of a number of point grafts scattered over the floor 
of the ulcer. 

In certain severe intractable cases the patient may be sent to the 
hospital and the ulcer curetted, with subsequent application of the skin 
grafts. 1 The immediate results of these operations, are very satis- 
factory, the ulcer healing rapidly. Great care must be taken to pro- 
tect the ulcer when the patient is allowed to resume the activities of 
his daily life, as these ulcers are apt to break down as rapidly as they 
heal . 

Ulcers about the external and internal malleoli are exceedingly 
difficult to cure. This area is drained by the lower communicating 
veins which join the plantar veins. In flat foot, the plantar veins are 
pressed upon and it is often impossible to heal the ulcers until the 
condition of the feet is corrected. We have seen cases of years' 
standing heal with no other treatment than strapping to relieve the 
flat foot, or the use of an arch support of the Whitman type. 




Fig. 312. — Late result of plastic in a child with deep congenital encircling bands of the 
leg. Marked improvement in function. 



DEFORMITIES OF THE LEG AND THIGH. 

Deformities of the lower extremities may be congenital or acquired. 
Of the congenital, we have two types: (a) Those caused by faulty 
development, as, the increase or decrease of the number of digits; 
absence of one of the bones, as the astragalus, fibula, etc.; (b) those 
caused by intra-uterine trauma, as congenital dislocations, club-feet, 
etc., also, those caused by adhesions and contractions of amniotic 
bands. Postnatal deformities may also be divided into several types: 
(a) Those arising from faulty growths, such as bow-legs, knock-knees, 
etc. ; (b) those resulting from nerve paralysis, as seen following infantile 

1 See Skin-grafting. 



DEFORMITIES OF THE LEG AND THIGH 



413 



paralysis; (c) those caused by fracture, dislocation, and evulsion of the 
joint; (d) those credited to the surgeon, due to faulty reduction, wrongly 
applied splints, lack of support, stiffness following too prolonged use 
of splints. Most of the above mentioned conditions are discussed 
under the chapters on Fractures and Dislocations and require no further 
mention. The special conditions will be covered in the following 
sections. 

Bow-legs.— Bow-legs is a condition caused by a lessening or reversal 
of the normal lateral angle between the thigh and the leg. If this 
change is no greater than that required to bring the axis of the thigh 
and leg into the same line, the condition will probably take care of 
itself; but if it has gone beyond this point, then the weight of the body 
tends to increase the defect. 




Fig. 313. — Genu valgum (knock-knee). Cured by cruciform osteotomy. 



Treatment. —A moderate degree of bow-legs, possibly due to the use 
of large diapers or too early standing, is usually outgrown. In such 
cases, cure may be hastened by the use of splints so that light pressure 
is made to correct the bowing. In children up to four or five years, 
an orthopedic brace, hinged at the knee and so adjusted as to apply 
continuous pressure, will correct the deformity in about six months. 
The brace should allow free use of the legs. In older children with 
aggravated bow-legs, operation (either osteoclasis or osteotomy) with 
correction of the deformity, is the only form of treatment which 
promises satisfactory results. 

Knock-knee.— Knock-knee is caused by an increase of the normal 
angle between the thigh and leg. If this change has gone so far that 
all the weight is carried upon the outer condyle, it demands correction, 
for the tendency is for the defect to increase constantly. 



414 MISCELLANEOUS AFFECTIONS OF THE LEG AND THIGH 

Treatment.— If the inner margin of the shoe is raised from one-eighth 
to one-quarter of an inch, the tendency to knock-knee is greatly dimin- 
ished. In young children, where the condition is not severe, this 
may be all that is required to effect a cure. Mechanical treatment 
is effective up to four or five years. The brace runs on the outer side 
of the knee and traction draws the knee away from the mid-line. There 
should be no joint at the knee. In order to prevent atrophy the brace 
should be removed once or twice daily for active and passive motion 
and massage. In older children, little result can be achieved by the 
use of apparatus; and in cases of marked deformity some form of 
operative treatment is required. 

TUMORS OF THE LEG. 

The tumors about the leg are not characteristic, but resemble those 
found in other portions of the body. Lipomata occur in the soft 
parts of the thigh. Fibromata occur in the skin and subcutaneous 
tissues. They should be removed, as they may, and frequently do, 
undergo malignant degeneration. Sebaceous cysts are very rare on the 
lower extremities. 




Fig. 314. — Ulcerated angioma of the thigh. 



Osteoma. — An osteoma of the femur at the location of the tendon of 
the adductor longus is not uncommon and is thought to be due to 
irritation caused by horseback riding. An interesting form of osteoma, 
which is known as a subungual exostosis, occurs beneath the nail of 
the great toe. At first it is painless and passes unnoticed, but later 
it raises the toe nail sufficiently to cause annoyance, and should be 
removed by turning back a flap consisting of the nail and its bed and 
chiselling away the exostosis. The flap can be sutured back in place 
without injury to the nail or its matrix. 

Sarcoma.— Sarcoma is not uncommon, and may arise from any of the 
tissue layers. Sarcoma of the bone occurs fairly frequently. It may 
give no symptoms until a fracture results from the weakening of the 



TUMORS OF THE LEG 415 

bone. In the vicinity of the knee, chronicity of the disease and dis- 
ability may lead to the suspicion of tuberculosis. Sarcoma of the long 
bones must be differentiated from bone cyst. 

Carcinoma.— Carcinoma as a primary disease seldom occurs on the 
lower extremity. Carcinomatous change of leg ulcers occurs much 
less commonly than might be imagined. Secondary carcinomata, 
occurring as metastatic growths, are fairly common and are occasionally 
the first intimation of cancer elsewhere, for example, carcinoma of the 
stomach or esophagus. The femur is the bone most frequently the 
seat of a metastatic growth. Hypernephroma may also occur secon- 
darily in the bones in the same manner as carcinoma. 

Occurring in long bones, most malignant growths require amputa- 
tion. Bone cysts heal by granulation when opened and curetted. 
Recently, success has followed the use of radium in selected cases of 
malignant bone growths. The treatment of malignant growths is 
given in detail in works on major surgery. 



CHAPTER XVI. 

MINOR SURGERY OF THE FOOT. 

Much that has already been said regarding the surgery of the 
upper extremity is applicable to the lower extremity; but in addition 
there are certain surgical conditions which occur so frequently on the 
lower extremity that they acquire special significance. Traumatic 
injuries, in the main, correspond to similar injuries in the hand and arm, 
with the exception that the function of the toes is less important to 
conserve than that of the fingers. In extensive injuries to the foot, 
the important factor in the treatment is the conservation of sufficient 
plantar surface to support satisfactorily the weight of the body. 




Fig. 315. — Fracture of the proximal phalanx of the first and second toe, caused by a 
box falling on the foot. Marked disability. 

INJURIES OF THE FOOT. 

The treatment of minor injuries to the foot consists in the care of 
the wound and the after-treatment, exactly as described under similar 
injuries to the hand. If the injury is sufficient to call for amputation, 
however, the situation is changed. Here, in addition to the care of the 
wound it is important to secure early healing; for temporary disability 



SPRAIN OF THE FOOT 



417 



in the case of an injured foot is much greater than after a similar 
injury to the hand. A satisfactory weight-bearing surface, rather than 
complete recovery of the digital functions, should receive first con- 
consideration in all injuries about the foot. 

SPRAIN OF THE FOOT. 

Because of their inherent strength the plantar ligaments are rarely 
sprained, but sprains of the dorsal ligaments are not uncommon. 
The injury usually occurs when the foot is "turned under," that is, 




Fig. 316. — Adhesive plaster strapping for sprained ankle. 

with forcible inversion and extension. The area of pain and swelling 
is located over the dorsum of the foot near the base of the metatarsal 
bones. There may be an associated fracture. 

Treatment.— If there is no fracture, the torn ligaments may be 

supported by adhesive straps so applied as to cause eversion and 

flexion. To accomplish this, a strip about 1 inch wide and 15 inches 

long is started on the inner margin of the foot about the middle of the 

26 



418 MINOR SURGERY OF THE FOOT 

first metatarsal bone and carried transversely across the sole of the 
foot to the outer margin, then obliquely across the dorsum of the foot 
to end on the leg above the ankle. Several overlapping straps are then 
applied. The patient may be allowed to walk at once. The strapping 
should be removed and reapplied every seven or eight days for about 
three weeks. Snug-fitting lace shoes are advised for two or three 
months. 

AMPUTATION OF THE TOES. 

It must be remembered that in the normal foot the weight of the body 
is borne by the heel and the heads of the metatarsal bones, especially 
the first. As weight-bearing is the chief function of the foot, all scars 
should be arranged, if possible, so that they will not be subjected to 
pressure. Amputation of the toes through the phalanges is likely to 
be followed by contractions which result in hyperextension of the 
stump. This condition is apt to lead to irritation and to result in 
painful ulcers upon the short stumps of the amputated toes. For 
this reason, disarticulation at the metatarsophalangeal joint is pre- 
ferred, except in exceptional cases. In the case of the great toe, if the 
stump is long enough it may be desirable to allow it to remain, in order 
to preserve the strength of the ball of the foot. This is usually accom- 
plished by disarticulation at the inter phalangeal joint by means of a 
flap-incision with a single plantar flap. The toe is flexed and a trans- 
verse incision is made across the dorsal aspect. The incision is deep- 
ened until it enters the interphalangeal joint and is then carried forward 
along the lateral surfaces of the toe for about half an inch, the ends of 
the lateral incisions being connected across the plantar surface and the 
anterior flap dissected away. The end of the phalanx is covered with 
the flap of thick plantar skin. 

Disarticulation of the metatarsophalangeal joint of the great toe is 
best accomplished by a racket incision or by the internal flap method. 
However, as it is most important to save the head of the metatarsal, 
any method may be used which will accomplish this result. 

In the racket method, the handle of the racket is placed to the outer 
side of the first metatarsal bone so that the resulting scar is drawn 
toward the mid-line of the foot and is not exposed to pressure by the 
shoe. 

In the internal flap method (Farabeuf), an incision is made around 
the base of the great toe except at the internal aspect, where the 
incision extends in a curve with the convexity forward along the inner 
side of the great toe, forming a flap large enough to cover the denuded 
area. The posterior ligament is cut through and the toe disarticulated 
from without inward. It is advisable, whenever practical, to suture 
the ends of the cut tendons together over the head of the bone. This 
is, however, not absolutely necessary. The skin-flap is then sutured, 
the line of suture coming close to the base of the second toe in order 
that the scar may be protected against rubbing by the shoe. 



AMPUTATION OF THE TOES 



419 



Disarticulation of the smaller toes is best performed by means of a 
racket incision. The handle of the racket extends from a point just 
over the head of the metatarsal bone to a point on the dorsum of the 
phalanx opposite the web of the toes. From the distal end of this 
longitudinal incision (handle of the racket), an elliptical incision is 
carried about the toe, inclined so as to be slightly more distal on the 
plantar than on the dorsal aspect. Care must be taken in the dis- 
articulation not to injure the transverse metatarsal ligaments. After 
hemostasis has been secured, the wound is sutured with silkworm gut 
and dressed with a dry dressing. In the case of the little toe, the 





Fig. 317. — Amputations of the toes. A. Amputations of the phalanges; a, is an 
amputation at the metatarsophalangeal joint, b one through the first interphalangeal 
joint. B. Amputations of the toes along with the metatarsal bones; a and c are amputa- 
tions of the great and little toes with the heads of the metatarsals respectively. As little 
of the bone is removed as possible. The dotted line shows the direction in which the 
bone is divided; b shows the removal of a toe with its entire metatarsal bone. 



handle of the racket is placed at the inner side of the metatarsal bone 
and the phalanx, in order to prevent irritation of the resulting scar by 
pressure of the shoe. After amputation of the toes, the patient 
should be kept off the foot for at least two weeks. 

Amputation of the toes with a portion of the metatarsal bone is some- 
times desirable in traumatic cases. This is commonly the case when 
the first or fifth metatarsal bone is involved. In these cases, the racket 
incision is made as above described, but the handle is prolonged to a 
point above the line of amputation. The bone is now carefully dis- 
sected out and cut through with a heavy bone-forceps. The sharp 
edges are removed with a rongeur forceps and the wound sutured as 



420 MINOR SURGERY OF THE FOOT 

described above. This operation is usually performed upon the first 
and fifth metatarsal bones and may be performed in case of necessity 
for disarticulation at the tarsometatarsal joint. However, disarticu- 
lation of these bones is ordinarily to be avoided because of the import- 
ant tendinous attachments to their proximal ends. 

Amputation of all the toes at the metatarsophalangeal articulation 
may be performed as follows: The toes are forcibly flexed and a 
curved incision with the convexity forward, is made from a point just 
above the metatarsophalangeal joint of the great toe to a similar point 
on the little toe, the convexity of the curve passing along the dorsum 
of the foot onto the web of the toes. With the toes extended, a similar 
flap is made on the plantar surface, the convexity extending onto the 
web of the toes and almost merging with the dorsal incision. The flaps 
are dissected back to the articulation and the tendons and ligaments 
cut through at this point. After hemostasis is secured, the skin is 
sutured with silkworm gut and the wound is dressed. A similar 
amputation, in which the tendons are left long and the anterior tendons 
sutured to the posterior, has been advised. The advantages of this 
procedure are problematical. It lengthens the time of operation, and 
in traumatic cases increases the chances of infection. 

Amputation through the Metatarsus.— This should be made with a 
long plantar and short dorsal flap, so that the scar will fall upon the 
dorsum of the foot and not be subjected to pressure. The incision is 
marked out with the dorsal incision directly at the plane of amputation 
and the plantar incision well distal to it. Both incisions are deepened 
down to the bone and the plantar flap dissected back, care being taken 
to keep the dissection close to the bones so as not to injure the plantar 
vessels. After the bones are divided, either with a saw or bone- 
forceps, the plantar flap is turned into position. It is advisable to 
make the plantar flap a little too long and trim it down after it is in 
position. Sutures are applied and the wound is dressed in the usual 
manner. 

PUNCTURE WOUNDS OF THE FOOT. 

Puncture wounds of the foot are very common, and the casual 
surgeon is frequently called upon to treat them. These injuries are 
most frequently caused by stepping upon a sharp instrument, such as a 
tack or nail. Many of these wounds heal without any signs of infec- 
tion and are associated with only an insignificant amount of pain, 
which rapidly disappears. Other cases seem to be doing well for a 
day or longer and then become gradually more painful, until deep 
inflammation is plainly evident. If signs of inflammation make their 
appearance within twenty-four hours, the infection is likely to be severe 
and to spread rapidly; while, on the other hand, if the infection becomes 
evident only after three or four days or longer, it is likely to be well- 
localized and to run a benign course. There is, however, one type of 
infection which is comparatively common after puncture wounds of the 



PUNCTURE WOUNDS OF THE FOOT 421 

foot and which does not become evident for several days after injury 
namely, tetanus. 

Tetanus occurs frequently after puncture wounds of the foot because 
of the constant presence of tetanus bacilli in the dust of the streets. 
Consequently, the possibility of tetanus must be considered in every 
case. 

Treatment.— In wounds of the foot, first seen by the surgeon after 
infection has become evident, there is no question as to the treatment. 
Free incision and drainage, in the same manner as for cellulitis of the 
foot, are the only treatments worth mentioning. The details will be 
found under Cellulitis of the Foot. 

In puncture wounds seen immediately after the injury, a most 
satisfactory plan is to swab out the tract with a strong antiseptic, such 
as carbolic acid or tincture of iodine. This is accomplished by the use 
of a small cotton swab dipped in the solution. If the wound is very 
small, a sharpened match or toothpick dipped in the antiseptic and 
then passed into the wound serves admirably. Following this, the 
wound is dressed daily and kept open with the swab dipped in strong 
antiseptic. If suppuration does not occur, the wound can be allowed 
to heal on the third or fourth day. If tetanus is feared, the wound 
should be kept open for ten days or longer and antitoxin given. 

Should tetanus antitoxin be given in every case? It is difficult to 
know just where to draw the line. It goes without saying that it is 
impracticable to give an injection of antitoxin for every puncture 
wound of the foot. Pin and tack wounds are common to everyday life 
and are rarely, if ever, followed by tetanus. On the other hand, the 
wound made by the rusty prong of a barnyard rake is very likely to 
cause tetanus. It is not rational to say that because tetanus occurs 
after puncture wounds, every puncture wound should be injected with 
tetanus antitoxin. Our knowledge of tetanus and the available supply 
of serum are both too small to permit us to use antitoxin so lavishly. 
In addition, antitoxin, besides being expensive, may be followed by 
unpleasant after effects. It is found to be a good working rule that, 
when the instrument causing the wound has been reasonably clean there 
is little or no danger of tetanus, and according to our present viewpoint 
antitoxin is then unnecessary. Concrete examples of what might be 
considered reasonably clean are : A clean nail which has recently been 
pulled from the wood (cultures have shown such nails are almost 
always sterile) ; a new nail or tack which has recently been unpacked ; 
a nail stepped on while in bathing whether rusty or not (these usually 
show no pathogenic bacteria and rarely cause any form of suppuration) ; 
and a wound made with a polished tool of any sort. 

On the other hand, when the instrument is probably contaminated, 
especially contaminated with refuse from stables, or horse manure, 
there is more danger of tetanus, and antitoxin should be given. A 
rusty nail is dangerous because of the dirt it carries into the wound 
on its rough surfaces, the rust itself being harmless. A dirty rake or 



422 MINOR SURGERY of the foot 

sharp stick are almost certain to carry some of the dirt from the street 
into the wound. Finally, it is possible for dirt from the street, the 
clothing, or on the surface of the body to be carried into the wound by 
flying shrapnel or bullets. In all these latter types of wounds (gunshot 
wounds), tetanus antitoxin should always be given. 

Between the two types mentioned, there are numerous injuries which 
are neither certainly clean nor very evidently contaminated. When in 
doubt, the use of antitoxin is the only safe method of procedure. 

In cases in which tetanus is feared, in addition to the prophylactic 
dose of 1000 or 1500 units of antitoxin, the wound should be opened 
widely and drained. It must be remembered that tetanus bacilli do 
not thrive in the presence of air, and consequently, it is better to leave 
such wounds widely open. Tetanus is more apt to follow a lacerated 
wound which has been complicated by gangrene than one which heals 
kindly. 

CELLULITIS OF THE FOOT. 

Cellulitis of the foot often develops from infections about the nails 
or from infected wounds of the foot. It usually spreads along the 
fascial and deep muscular planes and rarely involves the tendon 
sheaths. This is due to the fact that the tendon sheaths of the toes 
as compared with those of the hand are poorly developed and that the 
action of the tendons is limited. 

A clear conception of the sheaths about the tendons and the fascial 
plane is desirable in order to understand clearly the course of infection 
about the foot. On the front of the foot the sheath of the tibialis 
anticus extends from the upper margin of the transverse crural ligament 
to the interval between the diverging limbs of the cruciate ligament; 
the sheaths of the extensor longus and the extensor hallucis both extend 
from the point just above the level of the tips of the malleoli to the 
base of the metatarsal bones. On the medial aspect of the ankle the 
sheath of the tibialis posticus extends from about 4 cc above the tip 
of the malleolus almost to the tuberosity of the navicular. The 
sheaths of the flexor longus hallucis and the flexor longus digitorum 
extend from just above the tip of the malleolus to a point approximately 
opposite the base of the metatarsals. Externally a single sheath 
enclosing the tendons of the peronsei longus and brevis extends from 
4 cc above the tip of the malleolus to about the same distance below. 

In the toes the flexor tendons run in sheaths analogous to those on 
the fingers, but these sheaths are much less extensive. On the dorsum 
of the foot the sheaths are even less distinct than on the plantar surface. 

The strong plantar fascia covering the flexor muscles of the foot is 
a dense fibrous layer which consists of a heavy central portion and two 
lighter lateral portions. Collections of pus may occur between the 
skin and plantar fascia or beneath the plantar fascia. In both events 
there is little tendency for the inflammation to " point" externally 
for the thick skin of the sole and the plantar fascia act as barriers, and 



CELLULITIS OF THE FOOT 



423 



suppuration tends to extend in a direction along the line of cleavage 
and along the metatarsals to the dorsum of the foot. 

Incisions on either dorsal or plantar surface of the foot should be 
made in a longitudinal direction in order to avoid injuries to important 
deeper structures. The operation should be done carefully, and the 
exact location of the abscess determined. If only the extra-fascial 
space is involved, several incisions through the sole of the foot down 
to, but not through, the fascia may be all that is required; but if there 
is deep suppuration, the fascia should be slit longitudinally and the 
deep tissues broken through with the finger or a blunt instrument. 
Drainage with a rubber tube is imperative, for these incisions tend to 
close rapidly and hinder drainage. 





Fig. 318.— Anthrax of the foot, 
by excision. 



Cured 



Fig. 319. — Infection of the toe 
following perionychia. 



Occasionally, a case is seen in which plantar suppuration has been 
neglected and has finally perforated through an interosseous space 
between the metatarsals, appearing as a swelling on the dorsum of the 
foot. In such cases a second incision should be made on the dorsum of 
the foot and through-and-through drainage instituted. 

Suppuration may begin on and extend along the dorsum of the foot 
following the course of the tendons. It is usually the result of peri- 
onychia or a wound of the foot. 

Acute lymphangitis is frequently seen on the dorsum of the foot 
resulting from a small local infection, such as a blister caused by a 
tight shoe. The patient notices several red lines extending up the 
anterior aspect of the foot and leg from the region of the wound. These 
lines tend to run together forming a red strip, which gradually becomes 
less distinct as it passes upward; it is neither tender nor painful, but 
there may be associated general symptoms of greater or lesser severity. 
Lymphangitis is rightly regarded as a dangerous symptom. Unless 
relieved by incision and drainage of the focus of infection, the lymphan- 



424 MINOR SURGERY OF THE FOOT 

gitis is likely to extend rapidly and finally merge into spreading cellu- 
litis. When lymphangitis occurs, the original focus should be incised 
and well drained and a large wet dressing applied to the leg for the 
entire extent of acute inflammation. 

Cellulitis of the dorsum of the foot should be widely opened and free 
drainage secured by incisions parallel to the tendons and vessels. In 
the rapidly spreading type, which shows only slight induration of the 
tissues, multiple incisions through the skin and deep fascia in a longi- 
tudinal direction will relieve the tension, and often result in cure before 
suppuration has become localized. 

A case recently seen showed a few abrasions of the dorsum of the 
right foot and ankle which had been present several days. The patient 
suddenly had a chill and the leg grew inflamed across the dorsum of the 
foot and up to the knee in the course of a few hours. The temperature 
rose to 103°F. and there was delirium and marked prostration. Although 
multiple incisions of the foot and leg failed to show pus, the temperature 
fell in two days and recovery was rapid and complete. The wounds 
showed a chronic purulent discharge for about two weeks. It is pos- 
sible that recovery in these cases is due to increased circulation conse- 
quent upon the relief of tension. In the acute cases it is important 
to incise early and widely. 

A word of warning must be given at this point against the possibility 
of incising cases of non-suppurative inflammation, such as gout, 
rheumatism, acute arthritis, or acute bunions, in the belief that they 
are suppurative cellulitis. We have frequently seen this mistake made 
even by physicians of undoubted diagnostic ability. While it is 
important to incise suppurative cellulitis early, it requires the utmost 
skill to differentiate cellulitis of the foot from other conditions which 
closely simulate it. 



WEAK-FOOT AND FLAT-FOOT. 

This is the most common disability of the foot. In the milder 
types anatomically there is simply a slight bulging of the inner side 
of the foot; while in the severer types the plantar arch may have 
disappeared and there is permanent eversion of the foot. The condi- 
tion is not merely a dropping of the arch. There is, in addition, more 
or less fixed abduction of the foot so that the weight of the body falls 
at a point to the inner side of the plantar arch. 

In the many opposing theories of the primary cause of flat-foot 
there is one common point of agreement, namely, that eversion is an 
early factor. Hence, all muscles and ligaments limiting eversion and 
inversion are strong mechanical supports of the arch. 

In passive weight-bearing the leg has a tendency to slip backward 
and inward from the convexity of the arch. In weak foot this normal 
tendency becomes exaggerated and the ligaments and muscles become 



WEAK-FOOT AND FLAT-FOOT 



425 



so relaxed that deformity results. This subluxation consists of the 
rotation and mesial displacement of the astragalus. The remainder 
of the foot, including the os calcis, 



is everted, the anterior portion be- 
ing in fixed abduction. In the 
moderate and severe cases the 
diagnosis is easily made on in- 
spection. In the milder cases the 
deformity disappears when the toes 
are directed inward; while in the 
severer cases it persists in all posi- 
tions of the foot. 

It is important for the surgeon, 
before he attempts the treatment 
of flat-foot, to visualize thoroughly 
the mechanics of the normal foot, 
a short review of which follows. 

The normal foot has three points 
of weight-bearing: 

A. The os calcis. 

B. The distal portion of the 
first metatarsal. 

C. The proximal end 'of the 
fifth metatarsal. 

These three points form a tri- 
pod, which is the greatest number 
of supports that will not rock on an 
uneven surface. Between these 
three points are the three arches 
of the foot: A to B, the internal 
or long arch; A to C, the external 
or short longitudinal arch; B to 
C, the transverse or broad arch, 
extending from the distal border 
of the os calcis to the distal ends 
of the metatarsal bones. These 
three arches form a dome and it is 
through the highest point of this 
dome (D) that the axis of weight- 
bearing falls. 

The arches are normally sup- 
ported by two methods: (1) The 
static or stationary; (2) the dyna- 
mic or movable. The static sup- 
port is maintained by the keystone 

shape of the bones, their underlying ligaments, and the fascias bow- 
stringing the arch. The dynamic support is maintained by the 




Fig. 320. — Bicketic deformity with 
flat-feet center of gravity more lateral 
than normal. 



426 



MINOR SURGERY OF THE FOOT 



intrinsic muscles of the arches, together with the distant ones acting 
through their tendons. 




Inferior tibiofibular articulation. 



Ankle-joint. 

Tarsal articulations. 

'arsometatarsal 

articulations. 



Fig. 321. — Showing the short external arch. (Gray.) 



CHIEF SUPPORTS OF THE INTERNAL ARCH. 



Static 

Intrinsic longitudinal ligaments of articu- 
lation. 
Short and long plantar ligaments. 
Plantar fascia. 



Dynamic 
Abductor hallucis. 
Flexor brevis hallucis. 
Flexor brevis digitorum. 
Accessorius. 
Adductor obliquus. 
Tibialis anticus and posticus. 
Flexor longus hallucis. 



CHIEF SUPPORTS OF THE EXTERNAL ARCH. 

Static Dynamic 

Intrinsic longitudinal ligaments of articu- Abductor minimi digiti. 

lation. Flexor brevis digitorum. 

Long and short plantar ligaments. Peroneus longus and brevis. 
Plantar fascia. 



CHIEF SUPPORTS OF THE TRANSVERSE ARCH. 



Static 

Intrinsic transverse ligaments of articu- 
lation. 
Transverse fibers of the fascia. 



Dynamic 

Distal portion is supported by adductor 
transversus hallucis and obliquus. 

Proximal portion is supported by pero- 
neus longus. 



WEAK-FOOT AND FLAT-FOOT 



427 



As can be seen most of the ligaments, muscles, and tendons have 
oblique courses and thus may help support all three arches. For 
example, the peroneus longus helps support (1) the external arch, by 
passing under it; (2) the proximal portion of the transverse arch, by 
spanning it; (3) the internal arch, by passing obliquely forward and 
inward across the foot; and (4) all three arches by forming a sling 
in combination with the tibialis anticus. The same is mechanical] v 




Fig. 322. — Showing the deep static support of the dome of the foot. (Gray.) 

true of the tibialis anticus when working with the peroneus longus. 
It will be seen that the dynamic support, which consists of the muscular 
action of the flexor group, has the tendency to raise and shorten the 
arches. 

There are two ways in which the foot can weaken. The first is by 
the eversion or rolling out of the foot which carries the point D mesially 
towards AB or beyond it, thus throwing all the weight on one cord of 
the triangle, weakening it. This form of early weakening can easily 



428 



MINOR SURGERY OF THE FOOT 



be overcome in most cases by having the patient walk with the toes 
straight ahead or slightly turned in. This position of the foot in walk- 
ing brings the weight thrust of the body in the long axis of the foot and 
avoids the rolling action which takes place when the weight falls to the 
inner or outer side of the ankle. The second method of weakening is 
where there is a lengthening of one of the cords of the triangle with a 
corresponding flattening of the arch. This is probably most common 
in the transverse arch B C, but causes more disability and is more often 
seen by the physician in cases where AB is lengthened. As this 
lengthening takes place, point D is pushed mesially, and as the external 
arch holds its position, the line CB is rotated about the point C, carry- 




Fig. 323. — Section through tibia first metatarsal showing the long internal arch of 
foot, A B, the spanning fascia forming the superficial static support and the included 
soft parts or dynamic support upon which pressure is exerted in falling arch. (Gray.) 

ing the point B farther laterally from, and the point D farther mesially 
to, the original line AB. If the great toe is still pointing in the normal 
direction, it acts as a balancing arm to the inner side of the triangle 1 
and supports it; but if hallux valgus is present, there is no dynamic 
support left, and all the strain is thrown on the static support, which 
is incapable of long maintaining it. 

All splints for the arch must take the triangular shape of the weight- 
bearing portion of the foot into consideration. In the Whitman arch 



1 The importance of the great toe must not be underestimated. The muscles attached 
to this toe may be sufficiently powerful to sustain the body-weight as in toe-dancing 
hill-climbing, etc., and the toe in the normal position greatly strengthens the arch; but 
when the great toe is deflected outward as a result of improperly fitting shoes, the arch 
is seriously weakened. 



WEAK-FOOT AND FLAT-FOOT 



429 



support, the points A and B are carried well mesially, so that the plate 
takes the weight at the points of contact, A, B, C, or B, A, C, and in 
either case the foot must invert to bring C in contact with the ground. 
This inversion rotates the dorsum out and carries the tibia laterally, 
bringing the weight-bearing axis within the triangle. Again, the sup- 
port raises the arch, thus tending to approximate the points A and B, 
which in turn shortens the line AB. As these points are attached to 
C by firm bony attachments, the raising of the arch will tend to cause 
inversion of the foot and to force the axis laterally. 









INTER 




INTERNAL LATERAL 
LIGAMENT 

TIBIALIS POSTICUS 

INTEROSSEOUS CAL- 

CAN EO-ASTRAGMLCI D 



Fig. 324. — Showing the line of force falling well to the inner side of weight-bearing 

surface of the os calcis. (Gray.) 



The tendon of the flexor longus hallucis passes under the mesial 
border of the os calcis and then spans the arch of the foot like a bow- 
string, thus acting as a support for the arch as well as tending to rotate 
the dorsal surface of the os calcis outward, and by both these actions 
moving the weight-bearing axis outward in its relation to the weight- 
bearing points of the foot. If the great toe points either mesially or 
forward and is actually used in walking or standing, so that the effect 
of the flexor longus hallucis is preserved, not only is the arch protected, 
but the weight may be borne upon the tip of the great toe, thus forming 
a new point, B. A line drawn from A to this new point B will run 
well mesial to any point D can reach in rotation of the ankle. Hence, 
the use of the great toe is of extreme value in correcting the early stages 
of flat-foot. 



430 



MINOR SURGERY OF THE FOOT 



If the transverse arch B C is broken, the weight falls on the heads of 
the second, third and fourth metatarsal bones. This causes pressure 
on the plantar nerves of the toes, and builds up corns or callus beneath 
the heads of the bones. 




Fig. 325. — Plantar view of the foot showing the dome-like formation with three points 

of contact. (Gray.) 



Symptoms. —The symptoms, which may be present at any stage and 
may vary greatly in severity, depend largely upon the stretching of the 
muscles and ligaments. The patient with beginning weak foot may be 
subjected to considerable pain due to the strain put upon the soft 



WEAK-FOOT AND FLAT-FOOT 431 

parts, and yet show very little deformity; while the patient, whose 
arch has become completely obliterated and who shows marked 
deformity, may suffer no pain at all. In congenital flat-foot and 
acquired flat-foot of long duration, the joints have accommodated 
themselves to the change in axis and there is very little disturbance 
of function. From the above it is evident that in each case the treat- 
ment should be directed toward the functional disability rather than 
the anatomical one. 

Pain, referred to the inner side of the foot or even to the knee or hip, 
together with fatigue out of all proportion to the amount of exertion, 
are the earliest signs of weak foot. It is characteristic of this condition 
that the symptoms are relieved by rest and made worse by exertion. 

Treatment. —The movements of the foot should be restored to normal, 
and the foot should be placed in such a position that regeneration of 
the relaxed muscles and ligaments can take place, and so that the 
center of gravity will fall approximately through the center of the foot. 




Fig. 326. — Flat-feet. Center of gravity falling mesial to normal point. 

The treatment for the milder cases may be divided into three parts : 
(1) Support of the arch; (2) exercise to develop the muscles; (3) properly 
fitting shoes. 

1. The arch may be supported by means of adhesive-plaster strap- 
ping somewhat similar to the Gibney strapping for sprained ankle. 
A strip of adhesive-plaster strapping about 15 inches long and 2 
inches wide is applied to the outer side of the foot about the level of the 
external malleolus, and the foot is then adducted and inverted as far 
as possible, and the strap passed around the foot under the arch and 
up the inner side of the calf and held in position by one or two adhesive 
bands about the calf. A second strap is placed in the same manner, 
partially overlapping the first. These are then firmly held against the 
ankle by circular bands which draw the strapping firmly against the 
inner side of the leg. This treatment, combined with a suitable shoe, 
will often relieve the milder forms of weak foot, especially those in 
which a strain has caused sudden acute symptoms. 

Braces may serve as support for weak arches, but to be efficient, they 



432 



MINOR SURGERY OF THE FOOT 



must not only support the arch but protect the foot laterally as well, 
correcting the tendency to e version. The ordinary stock forms of 
arch support are usually unsatisfactory and are of little value. The 
sheet steel brace made upon a plaster model of the foot, with flanges 
along the internal and external margins deep enough to support the 
foot without preventing the normal movements, is the only type of 
arch support worthy of the name. Such a support should be worn 
constantly, and if properly constructed, can be worn indefinitely. It 
goes without saying that an arch support should never be applied 
to a deformed and rigid foot, until the rigidity has been overcome 
by appropriate treatment. 




Fig. 327. — A, the astragalo-navicular joint. The in- 
ternal flange of the brace should rise well above ah the 
prominent bones to a point about half an inch below the 
malleolus. (Whitman.) 




3» 



0'^f : 



Fig. 328. — B, the calcaneo-cuboid junction. The 
external flange extends from the center of the heel to a 
point just behind the base of the fifth metatarsal bone. 
(Whitman.) 




Fig. 329.— C, the great 
toe-joint; D, the center of 
the heel. (Whitman.) 



2. Exercises will accomplish a great deal toward the correction of 
this disability. Many patients with weak foot habitually toe outward 
to a marked degree. This in itself tends to increase the deformity. 
It is sometimes possible to cure a mild weak foot by correcting this 
position. The patient should be taught to walk with the toes pointing 
ahead. Voluntary exercises should be directed toward strengthening 
the adductor and plantar flexors. The patient should stand with the 
toes directed inward, and then raising the body on the toes, the knees 
being in full extension, sink slowly and rest the body on the outer 



HALLUX VALGUS 433 

borders of the feet. This exercise should be repeated about fifty times. 
Passive eversion of the foot, combined with plantar flexion, is also 
valuable. The development of the muscles attached to the great toe 
is of extreme importance. Exercises for this purpose may be impro- 
vised, and the patient should be told to use this toe in walking, that is, 
to make it bear a large part of the weight each time the foot strikes the 
ground. Massage and special gymnastics are not essential, but are of 
considerable value in certain cases. 

3. Proper shoes are necessary in every case. The narrow, pointed 
shoe is indirectly the cause of many cases of weak foot. The shoes 
should be large enough to give sufficient space for the anterior arch 
of the foot and for free movement of the toes. The shoe should 
conform to the shape of the foot, the internal border being practically 
a straight line. The inner border of the shoe may be built up from one- 
eight to one-quarter of an inch in order to throw the weight more 
toward the outer border of the foot. If the weak foot is raised just a 
fraction of an inch on the inner side, the center of gravity of the leg 
will be thrown nearer to the center of the foot. In some cases the 
change in the shoe with the building up of the inner margin of the sole 
and heel is all that is required. 

The severer types of rigid flat-foot and congenital club-foot of the 
flat-foot type require radical treatment. In general, the treatment 
consists in forcible overcorrection, fixation in the overcorrected position, 
and systematic manipulation, with the late treatment as outlined above. 
Details of treatment can be found in works on orthopedic surgery. 

HALLUX VALGUS. 

In hallux valgus the great toe is directed forward and outward 
instead of forward and inward. It is practically a subluxation of the 
phalanx on the metatarsal bone. Normally the enlarged head of the 
first metatarsal forms a prominence on the inner side of the foot where 
the great toe articulates with the first metatarsal. This prominence 
becomes exaggerated in direct proportion to the amount of abduction 
of the great toes from the mesial line of the body. When the bursa 
covering the prominence is exposed to injury and pressure by the shoe, 
the resulting inflammation is called a bunion. It seldom occurs except 
with hallux valgus, and is easily cured when the deformity is corrected. 
The inflammation of the bunion spreads to the periosteum and causes 
a productive periostitis. This enlarges and roughens the head of the 
metatarsal, which in turn causes more injury to and pressure on the 
bursa, forming a vicious circle. 

Hallux valgus is caused by shoes that are improperly shaped, the 
effect of the pointed shoe being to push the great toe outward and to 
crowd the small toes together. While the deformity begins at an early 
age and may progress rapidly, it rarely gives symptoms until late in 
life. The deformity, as such, rarely causes much pain; but the pain 
28 



434 



MINOR SURGERY OF THE FOOT 



of the irritated bunion over the prominence caused by the projecting 
head of the metatarsal bone leads patients to apply for treatment. As 
a rule, both feet are affected, but the symptoms are usually more 
marked on one side than on the other. If the reader will review what 
has been said in the discussion of flat-foot about the function of the 
muscles connected with the great toe in the preservation of the plantar 
arch, the association of hallux valgus with flat-foot and other deformi- 
ties of the foot will be more clearly understood. Improperly fitting 
shoes are often the predisposing cause of a whole train of symptoms 
referable to the feet. 

Treatment.— The first essential is the prescribing of a properly fitting 
shoe, by which all the pressure on the painful joint is relieved and the 
toe is allowed to assume its normal position. In cases not greatly 





Fig. 330. — Hallux valgus. Same 
patient shown in Fig. 331. (Ashhurst.) 



Fig. 331. — Hallux valgus. After 
operation. (Sesamoid bones restored 
to normal site beneath metatarsal.) 
(Ashhurst.) 



advanced, the use of a properly fitting shoe and daily manual correction 
of the deformity, combined with exercises for the disused muscles, will 
often result in considerable improvement. Individual braces, so 
arranged as to be worn inside the shoe to force the toe gradually inward, 
are of great value. A splint on the inner side of the foot, so adjusted 
as to permit elastic traction inward of the great toe, may be fitted to 
the foot and worn every night. 

It is important to remember that while the measures mentioned 
above are reasonably satisfactory in mild hallux valgus, they give little 
or no relief in the severe cases usually seen by the surgeon. Because 
in the early stage hallux valgus is painless or nearly so, the patient 
rarely applies for treatment until the deformity is quite pronounced. 
In such cases some form of operative treatment is almost always 
necessary. 



HOLLOW OR CONTRACTED FOOT 435 

There have been a great many operations advised for hallux valgus. 
One of the best is the following : An incision is made over the project- 
ing bone, and curved with the convexity upward so that the resulting 
scar will not be subjected to pressure. In the simplest form of opera- 
tion, the projecting condyle of the metatarsal bone is chiseled away 
smoothly and the wound is closed. Better than this is the cuneiform 
osteotomy, where a wedge-shaped piece of bone is removed, the toe is 
forced into place, and the foot is fixed in plaster for several weeks. 
Support of the plantar arch is usually necessary for a long period after 
the operation. 

In some cases, relief can be obtained only by complete resection of 
the head of the metatarsal bone. This removes the support of both the 
longitudinal and transverse arches, and should be performed only 
when the condition is extreme. Support of the plantar arch is always 
necessary for a long period after removal of this support. In connec- 
tion with this operation, a fascial transplant over the end of the meta- 
tarsal has been advised in order to facilitate the formation of a new 
joint. After the operation it has been our custom to adjust a lateral 
splint on the foot so that traction could be made upon the great toe 
to overcorrect the deformity. This splint should be worn for at least 
two weeks, after which time the patient may be allowed to walk with 
the arch well supported. The anatomical results are excellent, but 
there is apt to be considerable pain for several weeks or longer. 

HOLLOW OR CONTRACTED FOOT. 

Under this heading Whitman describes a condition characterized 
by an abnormally high plantar arch with contraction of the plantar 
fascia and of the extensor muscles of the toes. It is caused by the use 
of high heels, by excessive muscular action as seen in professional 
dancers, or possibly in some cases as a result of slight paralysis following 
an unrecognized poliomyelitis. Cases are seen in women and girls 
apparently due to the prolonged use of shoes which are too short. 
Possibly some cases are due to congenital shortening of the plantar 
fascia. The symptoms are those due to the cramped position of the 
foot and the loss of elasticity in the movements of the foot and ankle. 
Painful corns are common. 

When the foot is examined, it may be noted in the most marked 
type, that the weight is borne entirely upon the heel and the heads of 
the metatarsal bones. The toes are dorsiflexed so that they are held 
off the floor. 

Treatment.— Many cases, especially in women, are brought to the 
attention of the surgeon because of complicating corns or painful 
callus. In such cases, methodical massage and passive motion together 
with proper shoes may lengthen the contracted fascia and muscles and 
relieve the symptoms. 

In the severer cases, it is necessary to divide the plantar fascia and 



436 



MINOR SURGERY OF THE FOOT 



forcibly flatten the arch. When the extensor tendons are contracted, 
they should be divided. The foot is put in plaster in an overcorrected 
position and the patient allowed to use the foot so that the joints may 
be molded into shape while the foot is in this position. After about 
six weeks, the plaster is removed and the patient is allowed to walk 
about in a flat-soled shoe. Systematic massage is necessary for some 
months. 




Fig. 332.— The hollow foot, showing contraction of the toes. (Whitman.) 



MORTON'S DISEASE. 

Morton's disease, or anterior metatarsalgia, is a painful affection 
of the foot characterized by spasmodic pain in the region of the fourth 
metatarsophalangeal joint. In typical cases, the pain occurs after 
walking, especially in thin-soled tightly fitting shoes, and is frequently 
so severe that the patient seeks relief by removing the shoe and rubbing 
the foot. In almost every case, the pain is relieved by removing the 
shoe. 

Morton explains the disability by demonstrating that the plantar 
nerves might be pinched between the metatarsal bone and the adjoining 
bones, and, on this theory, the head of the fourth metatarsal has been 
resected in many cases, occasionally with marked relief. Whitman 
considers the disability as a symptom of weakness or depression of the 
anterior metatarsal arch, the pain being due to lateral pressure on the 
heads of the metatarsal bones, while the arch is depressed. It is 
probable that the depression of the arch is secondary to the cramped 
position of the foot in the narrow-pointed shoe so commonly worn by 
women. The condition is relatively much less common in men. 



PAINFUL HEEL 437 

Treatment.— For immediate treatment, a small gauze or felt pad 
placed beneath the anterior arch and held in place by adhesive plaster 
will prevent the depression of the arch, or a metal brace may be worn 
in the same position. If the patient can be induced to wear shoes that 
are broad enough and of the correct shape, the prognosis for the cure 
is excellent. 

In severe cases, forcible correction under anesthesia may be desirable. 
In many cases, thorough massage and passive motion are of great value, 
serving to lengthen the shortened distal tendons and to allow the toes, 
which are usually dorsiflexed, to assume the normal position and share 
in the weight-bearing function of the foot. 



ACHILLODYNIA. 

This condition is caused by a bursitis of the bursa between the os 
calcis and the tendo Achillis. The symptoms are pain at the back of 
the heel, increased by use, and tenderness at the location of the bursa. 

Although the bursae around the heel seem to have an added resistance, 
they are subject to the same laws that govern bursitis in other parts 
of the body. Because the heel is exposed to frequent trauma, the 
disease is likely to become chronic. When the enlargement of the 
bursa is extreme, it may be seen bulging outward on both sides of the 
tendon. Suppuration of the sac occasionally occurs. In old cases, 
the periosteum and the surrounding bone show proliferation and 
thickening. 

Treatment.— Complete rest of the affected part should be instituted 
in every acute case; otherwise, owing to the continual strain to which 
the part is subjected, the condition will almost certainly become 
chronic. A plaster bandage should be applied to keep the foot at right 
angles, and this should be worn until all symptoms have subsided. In 
less severe cases, the heel may be strapped firmly, to relieve the strain 
on the tendon. In persistent cases with great disability, excision of 
the bursa is indicated. 

PAINFUL HEEL. 

Pain upon the plantar surface of the heel is a common symptom of 
flat-foot. It also occurs as a complication of gonorrhea. It is appar- 
ently sometimes due to bursitis of a bursa located between the os calcis 
and the fatty tissues of the heel. In other cases, it is due to continued 
pressure on a localized exostosis usually situated at the attachment 
of the flexor brevis digitorum. 

Treatment.— The treatment should be directed tow T ard the cause. 
The pain may be relieve d by the use of an inner sole cut out so as to 
relieve the pressure. Operative treatment for the removal of the 
exostosis may be indicated. 



438 



MINOR SURGERY OF THE FOOT 



HAMMER-TOE. 

Hammer-toe is a deformity of the toe which consists in the hyper- 
extension of the first phalanx with flexion of the second. The terminal 
phalanx may be flexed or extended. The patient seeks relief from the 
pain due to the pressure of the shoe on the deformed toe. The deform- 
ity may follow untreated fracture of the toe; it may result from the 
wearing of shoes or stocking which are too short; or it may follow the 
wearing of pointed shoes which cramp the toes. 

Treatment.— Cases rarely come to the surgeon before the condition 
has become chronic; consequently, except in children, conservative 
treatment, which consists of fixation and daily massage, will accomplish 
little. 




Fig. 333. — Hammer-toe. Marked disability, caused by corn over the mid joint and 
under the nail. Cured by amputation. 

Forcible extension of he toe, with the division of the shortened ten- 
don and ligaments, together with the use of some form of apparatus 
for maintaining the toe in position, can be tried in adults ; but ordinarily 
the deformity must be treated radically, either by amputation of the 
toe or by excision of the proximal portion of the first phalanx. 



TENOSYNOVITIS ABOUT THE ANKLE. 



This is a rather common condition about the ankle-joint and may 
occur either as a complication of a sprain or as a separate affection. 
The symptoms are pain on motion and partial loss of function. Move- 
ments of the tendons are accompanied by a peculiar leathery crepitus, 
which can be felt by the examining hand. If the location of the syno- 



TENOSYNOVITIS ABOUT THE ANKLE 



439 



vial sheaths about the ankle are kept in mind, the diagnosis is simple. 
It should be remembered that these same sheaths may be the seat of 
tuberculosis. 




Fig. 334. — Gonorrheal involvement of the extensor tendon sheath. 

Treatment.— Adhesive plaster, so applied as to prevent the painful 
movements of the tendons, will usually relieve the pain. It is advisable 
to continue the strapping for at least three weeks, even when the pain 




Fig. 335.— Large ganglion on the outer side of the ankle connecting with the 

tendon sheath. 



and crepitus disappear after a few days. In a few cases, the symptoms 
are so acute that complete rest in bed is required during the first few 
days. 



440 



MINOR SURGERY OF THE FOOT 



Tuberculous tenosynovitis requires early removal of the affected 
tissue in the same manner as for the same condition occurring in the 
hand, care being taken to remove the entire area of disease. 




Fig. 336. — Multiple tuberculous involvement of the small bones of the feet and 
hands in a child, aged four years; three years' duration. Marked improvement fol- 
lowed the use of tuberculin. 



RINGWORM OF THE FOOT (TRICHOPHYTOSIS PEDIS). 

Ringworm of the foot is usually found on the soles of the feet where 
it may consist of one or more small patches the size of split peas, or 
it may involve the whole plantar region. 

Where the skin is thick as in the soles of the feet, ringworm gives an 
entirely different picture from that in other parts of the body. The 
spread of the lesion is irregular under the thick skin, giving a worm- 
eaten appearance. The vesicles are filled with a white, opaque fluid; 
they are usually small and numerous; and coalescing they produce a 
typical appearance that has been described as resembling tapioca. 
Where the skin becomes thin around the borders of the plantar area, 
the vesicles break and the heavy skin has a tendency to loosen. Second- 



PERFORATING ULCER OF THE FOOT 441 

ary infection is usually present, often producing intense burning and 
soreness. 

We frequently see ringworm involvement of the toe-nails similar to 
that of the finger-nails. 




Fig. 337. — Ringworm of the foot later spreading to all of the plantar area involving the 
nails. Did not respond to medical treatment. Rapidly cured by roentgen ray. 

DERMATITIS OF THE FOOT. 

Various types of dermatitis occur on the feet more frequently than 
upon the hands, possibly because of the fact that the feet are less 
frequently washed than the hand and consequently irritation is more 
common. Erysipelas may occur, but has no special significance in 
this region. Eczema is very common, frequently associated with 
ulceration about the ankle, and is apparently in some cases secondary 
to varicose veins. Roentgen-ray treatment has given good results 
in most cases and should always be tried. 

PERFORATING ULCER OF THE FOOT. 

This is a rather common affection, but in spite of its frequency is 
often undiagnosed. The patient usually presents himself with an 
ulcerated area of the foot which has existed for a considerable period. 
There is an area of callus around the ulcer, beneath which there is 
suppuration of a chronic variety. If the callus is cut away, the 
ulcer is completely exposed, usually about J to 2 cm. in diameter and 
extending a varying depth into the soft parts. Not uncommonly a 
probe may be passed into a sinus at the bottom of the ulcer which may 
reach the bone. There is ordinarily only a slight discharge. It is 
characteristic of this lesion that it is associated with little or no pain. 
While at periods the inflammation may spread to the surrounding area 



442 



MINOR SURGERY OF THE FOOT 



and cause some pain, the ordinary course of the ulcer is painless. 
Perforating ulcer of the foot commonly occurs in patients in whom there 
is a nerve lesion, either central or peripheral. It also occurs as a 
complication of certain general diseases, such as diabetes, rheumatism, 
syphilis, etc. In general surgical practice, diabetes is the frequent 
cause of perforating ulcer. Surgeons should be on the lookout for 
diabetic ulcer of the foot, for in many cases this is the first symptom of 
the disease. In an analysis of 91 cases, Gasquel found that 32 were 
subjects of locomotor ataxia, 17 of general paralysis, 14 were diabetics, 
and 12 had varied general diseases or lesions of the cord. ! There is 
apparently an added etiological factor, localized trauma, which pos- 
sibly acts as an exciting cause. In a subject who is liable to this 
lesion, the irritation of a sharp nail in the shoe or a slight wound or 
abrasion may mark the onset of the ulceration. 





Fig. 338. — Perforating ulcer of the 
foot and great toe following old un- 
treated Pott's fracture. Cured by 
astr agale cto my. 



Fig. 339. — Perforating ulcer of the foot 
in a syphilitic patient. 



Treatment.— Permanent cure is difficult or impossible. However, 
under adequate treatment of the predisposing cause and surgical care 
of the local condition marked improvement may be sometimes obtained. 
The thick horny layer of epidermis should be removed either with a 
sharp knife or by repeated applications of salicylic ointment (10 to 
20 per cent). The ulcer may then be packed with gauze soaked in 
balsam of Peru or some other stimulating agent. The gauze should 
be changed at frequent intervals. If this treatment is carefully 
carried out and the patient is kept off his foot during the period of 
treatment, a few cases may be cured. If the patient continues to use 
his foot, the constant trauma incident to walking is almost certain to 
prevent healing. In many cases, especially when the ulcer goes down 
to the bone, healing is almost impossible under any plan of treatment 
and the surgeon must be contented with avoiding inefficient drainage 



GANGRENE OF THE FOOT 



443 



and mixed infection, which result in spreading cellulitis. In a few cases 
where the ulcer is situated on one of the toes amputation may be 
performed, but this is likely to be unsatisfactory because the amputa- 
tion wound is slow to heal and persistent ulceration of the stump is 
very liable to occur. 




Fig. 340. — Diabetic gangrene in an old woman. 

GANGRENE OF THE FOOT. 

Gangrene of the foot probably always occurs secondary to the 
following conditions: Trauma, infection, and diseases of the circula- 
tory and nervous systems. 

As a complication of trauma it follows severe injuries where there is 
extensive destruction of tissue or great disturbance of circulatory- 
or nerve-supply, as in burns and frost-bite. It may also follow slight 
injuries, such as mild abrasions and operative wounds. 




Fig. 341. — Gangrene from frost-bite. 

In gangrene of the foot secondary to infection there are two types : 
(1) That which remains more or less local; (2) that which spreads 
rapidly, as in a gas-bacillus infection. 



444 MINOR SURGERY OF THE FOOT 

Under the heading " gangrene of the foot from circulatory disturb- 
ance" are grouped such conditions as obliterating endarteritis, diabetes, 
senile gangrene, and ergot poisoning. 

As a complication of nervous diseases it follows various trophic 
disturbances, such as Raynaud's disease, syringomyelia, etc. 

Treatment.— Cases not seen until the gangrene is fully developed 
should be put to bed and kept there until a distinct line of demarcation 
forms. In some cases the gangrenous area will be largely superficial 
after separation of the slough, and the wound will heal by granulation. 
Oftener the bone is affected so that one or more toes require amputation. 
An attempt should be made in every case to preserve as much as pos- 
sible of the weight-bearing surface of the foot. 

Gangrene of the foot is so often seen as a complication of diabetes 
that any injury to the foot of a diabetic patient should be given the 
most painstaking care. 

INGROWING TOE-NAIL. 

Ingrowing toe-nail is frequently the result of wearing ill-fitting shoes 
or stockings and is most often seen on the outer margin of the great 
toe. The skin at the edge grows over the corner of the nail and the 
pressure of the shoe causes the sharp corner of the nail to be driven 
into the skin. Infection with ulceration occurs and the condition is 
aggravated. In many cases, the patient, attempting to correct the 
condition, cuts away the corner of the nail and in so doing leaves a 
sharp, jagged piece of nail which only adds to the difficulty. In 
neglected cases, the nail may be deeply imbedded and partially covered 
by granulation tissue. Some cases of what are apparently simple 
ingrowing nails are actually ringworm of the toe. 

Treatment.— The treatment for mild cases consists in the use of 
proper shoes and attention to the proper cutting of the nail. The 
toe-nail should always be cut directly across and never pared or cut 
away at the sides. If infection occurs, most cases can be cured by 
packing a small wick of cotton between the edge of the nail and the skin 
and beneath the nail in such a manner as to evert the edge of the nail. 
We have found it convenient to use a wick dipped in a mixture of equal 
parts of tincture of iodine and alcohol. This dries quickly, acts as an 
antiseptic, and its use is usually followed by a subsidence in the 
inflammation. During the period of healing it is well to insist on the 
wearing of shoes with a portion of the toe cut away, so that there is 
absolutely no pressure upon the inflamed toe. When the inflammation 
subsides the patient is directed as to the care of the nails and the use 
of proper shoes. Whenever there is any evidence of irritation, the 
patient should be directed to wash the foot well with soap and water, 
to rinse the toe with alcohol and to apply a dusting powder, such as 
aristol or bismuth subgallate, around the irritating edge of the nail. 
The powder is dusted into the crevice between the skin and the nail; 



INGROWING TOE-NAIL 



445 



the corner of the nail is lifted slightly, and, with a sharp wooden tooth- 
pick, a small strip of cloth is touched beneath the corner of the nail 
and back as far as possible beneath the lateral edge. A portion of 
the strip should project between the edge of the nail and the skin and 
the excess of cloth is cut away. The cloth acts as a protection for the 
irritated tissues, and the powder which has been carried along with 
the cloth tends to prevent infection. 

Some patients with this trouble have cured themselves by allowing 
the toe-nail to grow long so that the end of the nail is bent over the end 
of the toe by pressure of the sock or shoe. The effect of this, provided 
there is not too much lateral pressure of the shoe, is to force the edges of 
the nail upward. We have seen this occur during the course of from 
four to six months in patients who have refused operation. Nails 
deeply embedded along both sides have flattened out, so that both 
lateral edges were entirely free. The bending of the end of the nail 




Fig. 342. — Operation for ingrowing toe-nail. In A is shown the method of cutting 
the lateral flap. In B the flap has been cut, the portion of the nail removed and the 
matrix beneath cut away. In C is shown the second method of performing the operation 
without forming a flap; a deep wedge-shaped gap is produced. D shows the final result 
in both cases, when the parts are brought together. 



downward causes pressure along the center or the nail which in turn 
causes the edges to flare upward. 1 This principle can be demon- 
strated by a piece of cardboard bent over the middle finger to represent 
the nail and held in place with the ring and index fingers. Bending 
the end of this piece of card over the finger tip causes the sides of the 
card to flare upward. 

In neglected cases and when the condition recurs frequently, opera- 
tion may be required. Operation will almost certainly be necessary 
if the patient continues to wear the sharp-pointed shoes that originally 
brought on the condition. The operation is performed as follows: 
After the foot is washed, the toe is painted with iodine, and a ligature 
is applied about the base of the toe. The dorsal and plantar nerve- 
branches are blocked by the use of 0.5 per cent novocain, and a double 

1 After a month or so the nails wear thin at the end and do not wear through the 
stockings. 



446 MINOR SURGERY OF THE FOOT 

wedge-shaped incision is made to include about one-fourth of the nail 
and the adjacent, inflamed overgrowth. On the dorsum of the toe, 
the incision is V-shaped, one arm of the V passing through the nail 
and the other arm being parallel to the lateral margin of the nail. The 
two arms meet just behind the matrix. As the incisions are deepened, 
they are made to approach each other so as to meet at a point about 
one-fourth of an inch from the surface. As a consequence, the end of 
the toe also shows a V-shaped incision with the point downward. The 
wedge of tissue is removed, the wound washed with 0.5 per cent forma- 
lin and the edges approximated by the use of a strip of gauze dipped 
in the same solution. The strip should be wrapped around the toe in 
a direction away from the incision and toward the healthy side of the 
toe. This bandage should be just firm enough to hold the edges 
together, but not tight enough to interfere with the blood supply. The 
ligature is removed and a dry dressing applied. No vessels are tied 
and no sutures are required. The toe dressing should be inspected 
daily, but if there is no evidence of infection or hemorrhage the strip 
need not be removed for four or five days. Healing is usually satis- 
factory after about ten days or two weeks. 

CLAVUS OR CORN. 

A corn is a localized thickening of the epidermis, occurring usually 
over the joints of the toes and due to the wearing of poorly fitted shoes. 
Corns are generally painful and exquisitely tender on pressure. Hard 
corns are situated on exposed parts of the foot, generally on the toes; 
soft corns occur between the digits where the skin is kept moist by 
perspiration. Corns usually become inflamed as the result of trauma; 
rarely as the result of a purulent infection. 

Treatment.— Treatment should first be directed toward the use of a 
properly fitted shoe. In the milder cases, this will often cause the corns 
to disappear within a few months. When they are acutely tender, a 
circular corn-plaster may be used to prevent direct pressure. If the 
corns are soaked for fifteen minutes twice daily in a solution of sodium 
bicarbonate, and pressure and irritation prevented by the use of a 
circular felt ring, they will gradually disappear. Patients commonly 
pare away the superficial layers. This gives temporary relief but 
does not cure the corn. Repeated applications may be made daily, 
or twice daily, of a mixture of salicylic acid and collodion. The 
following is a favorite formula: Extract of cannabis indica 0.6 
gm.; salicylic acid 2.6 gm.; collodion and flexible collodion, of each, 
8 cc. This mixture is painted on the corn night and morning for 
several days. At the end of this period, the corn is soaked in hot 
water and the corn, or part of it at least, will come away with a little 
rubbing or scraping. Several courses of treatment may be required 
before the corn is entirely removed. If the corn is especially tender 
after the treatment, it is advisable to allow a few days to elapse before 



PLANTAR WART 447 

beginning the second course. A very simple method of treatment, 
and one which is often successful, is the application of adhesive plaster 
directly over the corn. If this is kept up for several weeks it causes 
softening and sometimes permits the withdrawal of the entire corn, 
including the core. 

Soft corns between the toes may be treated by washing the feet in 
soap and water, drying carefully and removing the sodden epithelium 
by gentle scraping. The area between the toes is then wiped off with 
alcohol and again dried and finally dusted with borated talcum. A 
piece of cotton is placed between the toes in such a manner as to 
prevent contact. This must be continued daily for a long period. If 
the feet are properly cared for and the maceration of the skin by pers- 
piration prevented, as outlined above, the corn will usually disappear. 
Either the hard or soft variety may become inflamed, due to infection 
introduced through the use of dirty instruments used in cutting or par- 
ing the corn. Such a condition must be watched carefully and incised 
the minute there is evidence of pus. In making the incision, do not 
incise through the corn but close to the side, directing the point of the 
knife toward the core. It must be remembered that infection following 
the cutting or paring of a corn may lead to senile gangrene in old 
persons. 

CALLOSITIES. 

A callosity is a hard, horny, thickened patch due to a localized 
thickening of the epidermis. Callosities are frequent on the palms of 
the hands and plantar surface of the feet, but they may occur elsewhere. 

Treatment.— As the formation of callus is a protective against con- 
stant pressure or friction, treatment is ordinarily not required. In a 
few cases the patches cause discomfort. If the part is soaked in 
bicarbonate of soda solution, the epidermis will be softened and the 
superficial layers may be scraped away. If this is repeated several 
times, the thickening will gradually disappear. Not uncommonly 
infection will occur beneath a callosity and pus will form between the 
hardened layers and the true skin. In such cases, the callus should 
be cut away to allow free drainage. 

PLANTAR WART. 

This is a common condition and is very often associated with 
deformed feet and the use of improperly fitting shoes. The wart may 
be located on any part of the foot but is most often seen in the mid-line 
on the ball of the foot about the level of the head of the third metatarsal 
bone. The condition is frequently multiple. Because of the pressure 
upon the sole of the foot in walking, warts do not appear as in other 
parts of the body in the form of a papilla but are flat and surrounded 
by an area of callus formation and are sometimes called "warty 
callosities." If the callus is carefully cut away the warty nature of the 



448 



MINOR SURGERY OF THE FOOT 



growth may be easily seen. They cause severe pain on walking or 
standing and may become inflamed from traumatism. They are 
usually first noticed as small nodules the size of a pea and are likely 
to increase slowly in size to the size of a half dollar or even larger. 
The roots extend into the deeper tissues, and in the case of large warts, 
may reach to the metatarsal bones. 

Treatment.— Conservative treatment as outlined under the treatment 
of corns may be tried, and correction of malposition of the foot must be 
insisted upon. It is the ordinary experience that conservative treat- 
ment or the use of caustics only prolongs the treatment. Excision of 
the entire wart, including the roots, is the best form of treatment and 
usually leads to much less disability than the conservative measures. 
The incision is performed under local anesthesia and the callus outside 
skin removed first. This will often show that the wart itself is not as 
large as it first appeared. A circular incision is then made about the 
wart and the entire growth is dissected out. The wound is allowed 
to heal by granulation. Sutures are not advisable, as it is usually 
difficult to approximate the plantar skin without considerable under- 
mining, which is undesirable. If the wart is not too large, the patient 
may be allowed to walk about after a day or so. If a suitable dressing 
is applied so that the weight is not borne directly on the wound, there 
will be little pain, and walking will, under ordinary conditions, not 
interfere appreciably with healing. 




Fig. 343. — Supernumerary toes, right foot having separate metatarsal bone. 



DEFORMITIES OF THE FOOT. 

Congenital Deformities.— Webbed toes and supernumerary toes 
occur about as frequently as do the corresponding deformities of the 
hands. These conditions may be associated with other deformities 
such as club-foot, hare-lip, etc., or they may occur alone. Webbed 
toes rarely require treatment, because they cause no inconvenience. 
The presence of a supernumerary toe may cause difficulty in the 



DEFORMITIES OF THE FOOT 



449 



securing of suitable shoes and may cause malpositions of the feet 
because of crowding the other toes. In such cases, the extra toe should 
be removed. The methods are the same as those outlined for con- 
genital deformities of the hands. 

Acquired Deformities.— These are often the result of injuries to the 
foot, such as wounds or burns. The contraction of scar tissue on the 
sole of the foot may be sufficient to cause the patient to assume an 
unnatural attitude in walking, which in turn leads to secondary 
deformities. Many of the severe forms of acquired deformity are the 
result of a disease of the nervous system, either infantile paralysis or 
meningitis. 




Fig. 344. — Clubbed toes. Patent ductus arteriosus. 

The treatment of deformities due to injuries is largely preventative. 
The careful application of splints to prevent contraction of the tissues 
during healing, and the division of cicatricial bands when they occur, 
will do much to prevent the development of more serious deformities. 
In extensive burns of the feet, skin-grafting tends to prevent later 
contraction of the scar. For the acquired variety due to paralysis, 
orthopedic treatment is required combined, in favorable cases, with 
operation upon the tendons or nerves. 



29 



CHAPTER XVII. 
AFFECTIONS OF THE RECTUM AND ANUS. 



WOUNDS OF THE RECTUM. 

Wounds of the rectum may be caused by falls upon sharp objects, 
by lacerations during childbirth, or by foreign bodies introduced into 
the rectum. It is important to remember that injuries to the deeper 
structures may occur in cases where there is only a slight wound in the 
region of the anus. In a case cited by Park, a boy fell on the sharp 
picket of an iron fence which caused only a small laceration in the anal 
region but perforated the rectum at a point several inches from the anus 




Fig. 345. —Correct position for rectal examination. 

and entered the urinary bladder. In similar injuries a carefuly exam- 
ination should be made in order to determine if injury to the pelvic 
organs has occurred. 1 Rupture due to the instrumental distention of 
a cancerous or other form of stricture is not uncommon. 

Treatment.— In wounds of the anal region and terminal rectum the 
edges of the mucous membrane should be carefully approximated with 

1 An unusual cause of rupture was seen in a case recently admitted to the hospital. 
A workman in a garage placed, as a joke, the end of a hose against the anus of a fellow- 
employee who was leaning over a tub washing after the day's work. The water was 
suddenly turned on and the force of the stream distended the rectum and ruptured it. 
Similar accidents have been reported, as the result of epemata top forcefully injected iptQ 
diseased rectum^, 



DEFORMITIES OF ANUS AND RECTUM 451 

plain catgut sutures so passed as to permit the tying of the knots 
within the rectum. The skin in the region of the anus may be sutured 
with silk or silkworm gut. After the operation the patient should be 
put on a fluid diet and the bowels kept constipated with small doses of 
opium for three or four days. If the suture line shows signs of stitch 
infection it may be disregarded, but if deep infection occurs it is advis- 
able to divide the sutures and pack the wound with antiseptic gauze, 
allowing the area to heal by granulation. Iodoform gauze seems 
especially valuable in this region. The severer injuries of the pelvic 
organs referred to above may require laparotomy. 

FOREIGN BODIES IN THE RECTUM. 

It is not at all unusual for foreign bodies to be found in the rectum. 
Fecal masses often accumulate until they become as large as an apple, 
or even larger. In such cases there is apt to be constipation associated 
with intervals of diarrhea. Cathartics and enemata cause only a loose 
diarrheal movement which passes around the fecal mass but does not 
cause its expulsion. In addition to fecal concretions, almost every 
imaginable sort of foreign body has been found in the rectum. These 
are ordinarily introduced voluntarily, but they occasionally find 
entrance accidentally. 

In one case a patient is reported to have fallen upon a round, 
6-ounce soda-water bottle which was driven completely into the rectum 
by the force of the fall. Another case is reported in which a man, who 
is said to have forced a steam radiator-valve 2\ inches in diameter into 
his rectum, applied for treatment because he was unable to withdraw it. 
There is absolutely no limit to the number and variety of foreign bodies 
which surgeons have been called upon to remove from the rectum. 

Treatment.— Enlarge fecal masses can often be broken up with a 
gloved finger, after which they are expelled by enemata. If this is 
impossible a speculum should be inserted and the central portion of the 
mass removed with a sharp spoon, after which it can be easily broken 
up. When the foreign body is soft, as an apple or potato, it can be 
removed piecemeal with a sharp spoon. It has been advised to bore 
a hole in such a substance so as to relieve the suction from above, but 
this is rarely necessary. Wooden substances may be secured by the 
use of a corkscrew or sharp forceps. Round metal objects and glass 
bottles have been removed through the medium of obstetrical forceps. 
A general anesthesia, with or without division of the sphincter, is 
occasionally necessary in the removal of articles of large diameter. 

DEFORMITIES OF ANUS AND RECTUM. 

Imperforate Anus.— Congenital deformities about the region of the 
anus are very common. In the simplest form of imperforate anus the 
rectum is perfect except for a diaphragm which acts as a complete 



452 



AFFECTIONS OF THE RECTUM AND ANUS 



obstruction at the location of the anus, or the anus may be present and 
the diaphragm be located a short distance within the rectum. In such 
cases there is an abscence of meconium on the diapers after birth. 
Symptoms of intestinal obstruction slowly develop unless the condition 
is relieved. On examination the region of the anus bulges outward 
when the child cries, and the rectum, filled with meconium, can often 
be felt as a fluctuating mass just above the anus. In the severer types 
of congenital deformity, which are fortunately infrequent, there may be 
complete absence of the rectum, or the rectum may open into the 
urethra, bladder, or vagina. 




Fig. 346. — Membranous occlusion of the anus. (Lynch.) 

Treatment.— The milder cases should be incised at once. If the 
rectum can be felt, an aspirating needle should be passed through the 
thin diaphragm and a small amount of meconium withdrawn. This 
serves to make certain the location of the rectum before incision, and 
the needle is left in place to serve as a guide for the incision. A thin- 
bladed knife is passed along the aspirating needle and a small opening 
is made into the rectum. This opening should be enlarged by inserting 
an artery clamp or the finger and is kept open by a plug of gauze. As the 
opening tends to contract, it may be necessary to enlarge it from time 
to time by the use of some form of dilator. 



HEMORRHOIDS 453 

In severe cases the child should be removed at once to a hospital 
and the lower end of the bowel being identified by operation, an arti- 
ficial anus should be made as near the region of the natural anus as 
possible. As imperforate anus is invariably fatal if untreated, no opera- 
tive risk is therefore too great if there is the slightest chance of accom- 
plishing the desired result. 

ANAL FISSURE. 

This condition gives rise to a small ulcer at the anal orifice which 
is usually very painful and causes intermittent contractions of the 
sphincter. Either during or after defecation there is a severe, burning 
pain which may last several hours. Constipation and pruritus are 
usually associated with the fissure, which is seen sometimes as a narrow 
ulcer one-fourth to one-half of an inch in length, and sometimes as a 
large ulcer with indurated edges and a grayish base. The fissure or 
ulcer is often so painful that thorough examination without an anesthe- 
tic is impossible. 

Treatment.— A few ulcers will heal if touched with silver nitrate, 
if general measures are taken to prevent constipation, and if a cleansing 
enema is given once or twice daily. If this treatment is without 
result, the ulcer may be curetted under local anesthesia and the treat- 
ment continued as above, the ulcer being touched with a silver nitrate 
stick every four or five days. Pure ichthyol, applied locally, frequently 
promotes healing. In the severer cases of indurated ulcer, the sphinc- 
ter should be stretched under a general anesthetic. 1 After this has been 
done the ulcer is excised, care being taken to remove all the diseased 
tissue. The wound should be packed with iodoform gauze and the 
patient kept in bed for two or three days. It is advisable not to move 
the bowels for at least three days after operation. 

HEMORRHOIDS. 

Hemorrhoids are classified as internal or external, according to their 
position above or below the anal orifice. They may be inflamed and 
thrombosed, in which case they are very painful ; or they may remain 
quiescent, producing discomfort merely from their size. An internal 
pile may prolapse through the anus and become strangulated by the 
spasmodic contraction of the sphincter muscle, in which event it soon 
becomes thrombosed and very painful. If it is reduced when first 

1 Lynch describes divulsion of the sphincter as follows: "With the patient in the litho- 
tomy or Sims' position (it is taken for granted that the operator wears gloves) the left 
thumb is thoroughly lubricated and gradually introduced into the rectum. The sphincter 
is gently dilated, pressure being made toward the posterior commissure. The second 
thumb is now introduced and, with both thumbs in the rectum, the sphincter is dilated 
or divulsed." He calls attention to the fact that divulsion should only be performed with 
the patient in the third stage of anesthesia and points to the danger of overstretching 
with temporary or permanent paralysis of the muscles. Jerome M. Lynch in Johnson's 
Operative Therapeusis, New York, 1915. 



454 



AFFECTIONS OF THE RECTUM AND ANUS 



strangulated the pain will be relieved at once; but if it is allowed to 
become thrombotic the pain persists even after reduction has been 
accomplished. Frequently the first symptom of hemorrhoids is bleed- 
ing during movement of the bowels. 

Hemorrhoids may be, and frequently are, produced by straining 
efforts at stool in attacks of diarrhea or in chronic constipation. In 
a few cases they are secondary to pelvic or abdominal disease, such as 
cancer of the rectum, fibroid tumor of the uterus, cirrhosis of the liver, 
and other similar conditions. 

External Hemorrhoids.— These appear as small tumors about the 
margin of the anus. They may become thrombosed and are then very 
painful. Bleeding is common, usually following ulceration or rupture. 
Less frequently they become infected and form a small abscess. 







**,«. 




jot t8s 


**■'■*■ 



Fig. 347. — External hemorrhoids. 



Treatment.— Conservative treatment consists of hot and cold douch- 
ing followed by the use of a soothing ointment. In favorable cases 
the thrombosed piles gradually grow less painful and the thrombus 
is replaced by scar-tissue. After each movement the anus should be 
carefully washed, an ointment applied and an attempt made to reduce 
the hemorrhoids up through the anal orifice. Although they immedi- 
ately recur, this attempt at reduction relieves the engorgement, lessens 
the pain, and has a general beneficial influence. Operative treatment 
is usually followed by more rapid healing and less disability. Under 
local anesthesia the tumors are excised, the vein ligated, and the 
denuded area touched with tincture of iodine. The wound is then 
dusted with iodoform, and a gauze dressing, held in place by a T-binder, 
is applied. The patient should be kept at rest for several days, the 



HEMORRHOIDS 



455 



bowels not being moved before the third day. The after-treatment 
consists of careful attention to the bowels to prevent constipation and 
strict attention to cleanliness after each bowel-movement. It is well 
to advise thorough cleansing of the anal region with soap and water 
after defecation. 

A large per cent of internal and external hemorrhoids can be cured 
by simply stretching the sphincter. 

Internal Hemorrhoids. — The chief symptoms of internal piles are 
hemorrhage and protrusion. Many patients have learned that they 
can prevent serious annoyance if they avoid constipation and carefully 
reduce the protrusion after every movement. A small, daily dose of 
compound licorice powder or of mineral oil serves to keep the move- 
ment soft. When the pile becomes strangulated, thrombosis is likely 




Fig. 348. — -Internal hemorrhoids, mild. 



to occur. This condition results in a sensation which is similar to the 
desire to defecate and, unless patients are warned against it, they will 
strain at stool in an ineffectual attempt to remove the irritation, thus 
making the condition more pronounced. 

Treatment.— Palliative treatment consists in daily cold water 
enemata, immediate reduction when prolapse occurs, prevention of 
constipation, and the use of ointments and suppositories. A supposi- 
tory containing 5 grains of ichthyol, 5 grains of tannic acid, and 10 
grains of extract of hamamelis, has been found especially useful. 
Belladonna ointment containing tannic acid, or opium, or both, is 
indicated when the pain is severe. When bleeding is excessive, adren- 
alin applied locally, either in solution or in a suppository, may give 
good results. 

The operative treatment consists of the removal of the troublesome 



456 



AFFECTIONS OF THE RECTUM AND ANUS 



pile. In cases which are not too extensive and where the piles are 
situated near the anal orifice, the operation may be performed under 
local anesthesia. In this method the patient is prepared by catharsis 
and a cleansing enema, the anal region is shaved, and the skin is pre- 
pared for operation. With the patient in the Sims' position the area 
about the pile is well infiltrated with 0.5 per cent novocain solution. 
In order to expose the operative field an assistant draws the buttocks 
apart, and the patient is told to bear down as though at stool, causing 
the pile to protrude from the anus. When properly anesthetized 
it may be clamped and drawn down with moderate tension and without 
pain. If the base of the pile can be exposed by this method it can be 
removed under local anesthesia; if not, the case is not suitable for this 




Fig. 349. — Prolapsed internal hemorrhoids showing hypertrophied and inflamed papilla. 

(Lynch.) 



operation and sacral or general anesthesia is advised. When the base 
is exposed an incision is made through the mucous membrane about the 
pedicle and the pile is dissected free. The pedicle is now transfixed 
and tied with a silk ligature and the pile is cut away. One or 
two sutures may be taken in the mucous membrane if there is much 
bleeding. The patient should be kept in bed for three or four days, 
the bowels being moved on the third day. In ten days the parts 
should be examined and if the ligatures are still adherent they should 
be removed. 

DILATATION OF THE SPHINCTER. 

In some cases, either for examination or as a preliminary to operation, 
it is well to dilate the sphincter ani. When this is to be done as part 



INTERTRIGO OF ANUS 457 

of an operation, it is well to have the patient well anesthetized and in 
the lithotomy position. In other cases, dilatation may be accomplished 
upon ambulatory patients under nitrous oxide anesthesia but this is 
usually unsatisfactory. When nitrous oxide is used the patient is 
placed in the Sims' position with the knees drawn up and the dilatation 
is performed after cleansing the anal region well with soap and water. 
It is considered best to have the patient take a soap-suds enema before 
coming for treatment, as this empties the lower bowel and prevents 
defecation for a short period after the operation. The patient being- 
prepared, the surgeon lubricates the gloved index fingers and inserts 
them into the rectum in such a manner as to bring the dorsal surface 
of the fingers into approximation. The fingers are now separated 
so as to exert pressure on the sphincter ani successively in various 
directions. 1 As the dilatation progresses the fibers of the muscles can 
be felt to give way and the mucous membrane will show a number of 
small, superficial tears. Too rapid dilatation is to be avoided because 
a deep perineal tear may result. When dilatation is complete, several 
fingers can be easily introduced into the rectum. If the operation is 
done under nitrous oxide anesthesia the patient should rest for a short 
period, an hour or longer before being allowed to go home. In general, 
stretching of the sphincter is accomplished much more satisfactorily 
under deep ether anesthesia, in which case the mechanism is the same 
but the patient should remain in bed for at least twelve hours. 



INTERTRIGO OF ANUS. 

Intertrigo is a form of superficial dermatitis commonly seen where 
skin surfaces are in contact. It is very common about the anus, 
especially in hot weather. Acute cases usually show only redness of 
the skin; but chronic cases show thickening and induration, some cases 
going on to true eczema. Irritation from discharges of various sorts, 
from perspiration, or from lack of cleanliness, is the common cause. 
Horseback riding, through the irritation of the saddle may cause an 
acute dermatitis, especially among inexperienced riders, and this 
condition may be associated with blister formation. 

Treatment.— In the early stage, if the parts are kept dry and clean, 
the condition will heal rapidly. The skin surfaces are dusted with 
talcum powder and kept apart with cotton. After defecation the parts 
are well cleansed with soap and water, carefully dried, and again 
dusted with powder. A satisfactory powder for conditions of this 
sort is made by mixing one part of calomel with four parts of talcum. 
This is drying and at the same time antiseptic. In more obstinate 
cases, zinc ointment and other remedies for eczema may be required. 

1 See foot note under treatment of Anal Fissure, p. 453. 



458 AFFECTIONS OF THE RECTUM AND ANUS 

PRURITUS ANI. 

Itching about the anal region, which is actually a symptom and not 
a disease, is found in patients who suffer from intertrigo. In addition 
it may be caused by any form of continued irritation, either local or 
reflex, or it may be present as a true neurosis. 

Pinworms, diabetes, constipation, gout, jaundice, bladder calculi, 
alcoholism, and ovarian disease are a few of the conditions which are 
found associated with pruritus ani. In the beginning the itching is not 
troublesome, occurring only at night ; but later it may become continu- 
ous and so severe at night that the patient is unable to rest or sleep. 
When long protracted, the skin may dry and crack, showing numerous 
abrasions from scratching; in other cases, the area is pale, moist, and 
slightly edematous. Pruritus in children and young adults is almost 
invariably associated with pinworms. 

Treatment.— If any cause can be found for local irritation, it must 
be removed before the pruritus can be relieved. Fissures must be 
cured, pinworms expelled, hemorrhoids removed, and all other local 
diseases appropriately treated. When this has been accomplished, 
and in cases where no local cause can be found, the patient should be 
given treatment to improve his general health, combined with local 
applications to relieve the itching. Constipation should be avoided 
and dietetic errors, as well as excessive use of alcohol, coffee, and 
tobacco, should be corrected. 

For local treatment, an ointment composed of camphor, gr. vi, 
carbolic acid, gr. xxx, calomel gr. xv, and zinc oxide ointment up to 
one ounce, has been found of value. Bathing the parts with witch- 
hazel or dilute solutions of alcohol may give relief. 

A dusting powder of equal parts of calomel and camphor mixed with 
20 to 30 parts of talcum or starch may be of value. The roentgen ray 
or ultra-violet light may give marked relief in suitable cases. 

In persistent cases, relief may follow the stretching of the sphincter, 
either manually under anesthesia or gradually by use of rectal dilators. 
Hard rubber dilators are used in the gradual dilatation of the rectum and 
should be applied the first few times by the physician. A small 
dilator is well lubricated and inserted into the rectum and allowed to 
remain for from fifteen to thirty minutes. This is repeated on the next 
day and the patient, after instruction in the use of the dilators, is told 
to continue the treatment at home. After several days the largest 
rectal dilator can be introduced, and this is continued once or twice 
daily for two or three weeks. Dilatation can be combined with the use 
of the ointment mentioned above. All cases, except those due to some 
form of easily curable local irritation, are likely to be very intractable. 

ISCHIORECTAL ABSCESS. 

Abscesses about the anus are generally known as ischiorectal 
abscesses, although they are not always confined to the ischiorectal 



ISCHIORECTAL ABSCESS 



459 



space. The abscesses may be superficial or they may occur in the 
wall of the rectum or in the perirectal space. The superficial type 
about the margin of the anus is sometimes called a marginal or perianal 
abscess. The infection may find entrance through an infected hair 




Fig. 350. — Acute ischiorectal abscess. 



follicle, beginning as an ordinary boil, or through a small break in the 
mucous membrane (from a fissure or ulcerated pile), or possibly through 
the unbroken skin. It is possible that many cases are due to infected 
areas in the pockets and crypts formed by the mucous membrane of the 




Fig. 351. — Perirectal abscess. (Lynch.) 



lower rectum just above the internal sphincter. Such cases begin as 
a small localized abscess which breaks through the rectum into the 
ischiorectal space, giving the symptoms of a deep-seated boil. Colon 
bacilli are most frequently found as the exciting cause, either alone or 



460 



AFFECTIONS OF THE RECTUM AND ANUS 



in combination with streptococci or staphylococci. Tuberculous 
abscesses in this region are frequently seen. 

After pus forms in the ordinary form of ischiorectal abscesses, it 
tends to burrow upward through the loose areolar tissues surrounding 
the rectum, rupturing into the bowel or extending upward into the 
pelvis. Spontaneous rupture externally through the skin is not 
uncommon. If the abscess ruptures into the rectum, complete healing 
is very rare. The ordinary history of such a case is severe and gradually 
increasing pain until the abscess ruptures, followed by a more or less 
continuous discharge and partial relief from pain. This may continue 
for many weeks, periods of relief alternating with periods of acute pain 
due to the obstruction of drainage. Spontaneous cure is rare. Occa- 
sionally cases occur in which the patient makes no complaint of pain, the 




Fig. 352. — Dermoid of the gluteal region size of an orange ; contents mostly hair; 
present from childhood. Acutely inflamed, simulating ischiorectal abscess. 

only symptoms being fever and toxemia. This is especially likely to 
occur in patients already sick with some other disease, and for this 
reason it is important to examine the ischiorectal region carefully in 
bed-patients running an unexplained fever. On examination an area of 
swelling and induration is easily made out. Superficial redness is the 
rule. 

Treatment.— Small perianal abscesses which are located external to 
the sphincter should be opened by a radial incision and packed with 
loose gauze. The more deeply located ischiorectal abscesses should 
be opened by an incision parallel to the sphincter muscle. 

It is most important in all these cases to open the abscess before it 
ruptures into the rectum. If this has not yet taken place and the 
abscess is widely open, healing will take place in about the same time 



F1STULA-IN-AN0 461 

as in similar abscesses occurring elsewhere. However, if rupture into 
the rectum has already occurred, or if the infection has begun in the 
lower rectum, the opening tends to persist and an ischiorectal fistula 
results. In abscesses which have already ruptured into the rectum 
the treatment consists of thoroughly opening the abscess-cavity and 
the division of the sphincter under general anesthesia. The cavity 
is then packed with antiseptic gauze and the patient is confined to bed 
for several days. 

A special type of abscess which occasionally occurs is located in the 
wall of the rectum above the anus. It should be opened, after dilatating 
the sphincter, by a longitudinal incision through the wall of the rectum 
into the indurated tissues. Usually it is better to divide the sphincter 
at the same time and to keep the patient in bed for about a week. In 
ischiorectal abscesses, just as in other conditions about the rectum, 
it is wise to keep the patient constipated with small doses of opium for 
several days after operation. This gives the injured tissue rest until 
the immediate effects of the trauma have disappeared. When the 
bowels finally move it is advisable to introduce a few ounces of olive 
oil into the rectum before the movement takes place. 

Tuberculous ischiorectal abscesses should receive radical treatment. 
If possible, all the tuberculous tissue should be dissected out. 




Fig. 353. — Diagram of three forms of anal fistula. A, complete fistula; B, incomplete 
internal fistula; C, incomplete external fistula. (Roberts.) 

FISTULA-IN-ANO. 

Fistula in the region of the anus may result from an abscess which 
has not been properly drained, the constant movements of the parts 
preventing complete healing; or it may occur in cases where there is no 
history of acute infection, the continuous discharge being the first 
symptom noted. The latter type is likely to be tuberculous. There 
are three distinct varieties: blind external fistula, blind internal fistula, 
and complete fistula. These names are sufficiently descriptive to 
indicate the chief forms; but in chronic cases the fistulse become most 
complex, having several external openings, and one or more into the 
rectum. 1 When opened, fistulse, even those which appear simple on 
external examination, are likely to show many branching fistulous 
tracts. After a fistula reaches the chronic stage, the walls become 

1 In hospital practice cases are frequently seen showing large areas of induration and 
numerous openings. In a case treated by one of us, one of the many openings was 
located on the thigh at the level of the upper part of the popliteal space. All the openings 
were discharging pus and gas. 



462 AFFECTIONS OF THE RECTUM AND ANUS 

fibrous and cannot collapse. As a consequence, spontaneous healing 
is very rare. The chronicity of the lesion depends in part upon the 
constant reinfection of the tract at each movement of the bowels and 
in part on the constant movement of the parts with respiration, 
defecation, etc. 

Symptoms.— The symptoms are a more or less constant mucoid or 
mucopurulent discharge, usually associated with pain. In some cases 
the pain may be entirely absent. On examination an area of indura- 
tion is found near the rectum, sometimes extending a considerable 
distance upon the buttocks and thighs. In external and complete 
fistula?, the mouth of the fistula may be made out as a dimple in the 
skin which readily admits the examining probe. In blind internal 
fistula?, the deep induration is felt but there is no external opening. 
If a speculum is used, the internal opening, which is usually situated 
about one inch inside the anus, may be located by the small amount of 
pus that is often found exuding from it. If the probe is introduced 
into the external opening it can occasionally, with careful manipulation, 
be made to emerge from the internal opening into the bowel. A large 
percentage of all fistula? are tuberculous in origin, although at times 
they may become acutely inflamed when invaded by mixed infection. 
Tuberculosis of the lungs is likely to be present in tuberculous fistula 
although in many cases it is arrested. Occasionally the internal 
opening may be detected by the use of an injection of colored fluid, 
such as a 0.5 per cent solution of methylene blue. 

Treatment.— Palliative treatment consists of hot sitz-baths for the 
relief of pain and measures to increase drainage and to aid healing. 
The external opening of the fistula is kept open by the application of 
mild antiseptic ointments and occasional swabbing of the fistulous 
tracts with tincture of iodine or pure carbolic acid. Only exceptionally 
will this form of treatment be followed by cure. The writer has 
recently seen two cases, in which operation was refused, cured by this 
method combined with small doses of a stock vaccine containing colon 
bacilli and mixed staphylococci. The beginning dose contained 
10,000,000 colon bacilli and 40,000,000 staphylococci. This was 
slowly increased, at weekly intervals, to a maximum dose five times as 
large as the initial dose. However, these cases were exceptional, and 
conservative treatment results in failure in most cases. Another 
method which he has employed in cases where the probe could be 
passed into the rectum has given satisfactory results in most of the 
cases in which it has been tried. The essential part of this treatment 
is the application to the tract of silver nitrate and alcohol. A bead of 
silver nitrate was fused on the end of a probe and passed through the 
tract. Alcohol was then injected through the fistula to wash it out. 
This was repeated every three or four days for several weeks. If the 
alcohol did not pass through the tract the treatment was stopped, 
Recurrences so far have been about 25 per cent. 

The radical treatment consists \x\ either inqsion, or excisign , Inqimiij 



FISTULA-IN-ANO 



463 



should be performed in the following manner: After preliminary 
preparation, which consists in catharsis and a cleansing enema given 
the day before the operation, the region is well washed with soap and 
water and rinsed with sterile water. Small, submucous fistulas, which 
do not pass deeply into the sphincter, can be treated under local anes- 
thesia. Ordinarily, a general anesthetic is preferable. The patient 
being anesthetized is placed in the lithotomy position and the sphincter 
is dilated. As a preliminary to the operation the fistula should be 
injected with a 1 per cent solution of methylene blue or a 2 per cent 
solution of potassium permanganate. 1 A probe is now introduced 




Fig. 354. — Recurrent ischiorectal abscess. Multiple sinuses with cellulitis, 
excision, followed by skin-grafting and cure. 



Wide 



into the external opening and an attempt is made to cause the end of 
the probe to enter the bowel. If this is impossible the finger is inserted 
into the rectum and the probe is manipulated so that its end can be 
felt beneath the mucous membrane. At the thinnest point the probe 
is forced through the mucous membrane into the bowel. Using the 
probe as a director, a radial incision is made dividing all the tissues 
between the rectum and the probe, including the sphincter muscle, 

1 The injection of a colored solution renders the tract easily visible and is a very 
valuable preliminary to operation. However, it is necessary to warn the operator that 
occasionally, for one reason or another, certain branches of the fistula may not receive 
the solution and will consequently be unstained, 



464 AFFECTIONS OF THE RECTUM AND ANUS 

When this has been accomplished, the cavity of the fistulous tract is 
inspected and any branching fistulous tracts are opened and well 
curetted, care being taken to incise the sphincter at only one point. 
The cavity is packed with iodoform gauze and a soft rubber tube is 
inserted in the rectum. The patient is kept in bed on a fluid diet, 
small doses of opium being used to prevent movement of the bowels. 
The dressings are changed every day, or oftener if required, and the 
bowels are moved on the fourth day. Following this the wound is 
cleansed with soap and water or a weak antiseptic solution after every 
movement and packed with antiseptic gauze. Care must be exercised 
to keep the wound widely open, to allow it to heal from the bottom. 
If the granulating surfaces are allowed to bridge over superficially 
before the deep area has healed completely, the operation is almost 
certain to end in failure. 

Excision is preferable in most cases and is indicated when the 
condition is chronic and where there has been considerable fibrous 
change in the walls of the fistula. In this operation the entire fistulous 
tract is dissected out. A preliminary injection of staining solution 
into the fistula is of considerable aid in the location of the fistulous 
tract. The sphincter is divided in the same manner as for incision, 
and then the fistulous tract is identified and completely excised. The 
after-treatment is the same as after incision. 

A modification of the above method is known as excision and suture. 
The fistula having been fully excised, the wound is completely closed, 
by buried catgut sutures in the deeper parts of the wound, chromic 
sutures in the mucous membrane, and silk sutures in the skin. When 
successful, healing is rapid under this plan; but owing to the difficulties 
in asepsis the wound is likely to become infected which leads to a 
recurrence of the fistula. Indeed, in all cases the results are likely to 
be discouraging, two or more operations frequently being necessary 
before cure is complete. 

Tuberculous fistula is a painless lesion, as a rule, and consequently, 
except for the discharge, causes the patient little or no inconvenience. 
Operation has been advised against by some surgeons on the ground 
that pulmonary tuberculosis may be aggravated by the closure of the 
fistula. This is apparently not true. What happens in these cases is 
that the pulmonary lesion is made active by the anesthetic rather than 
by the operation. In tuberculosis, especially, complete excision must 
be performed, and, because of the danger of a latent lung-lesion 
becoming active, local anesthesia is preferred to any form of general 
anesthesia. In cases of tuberculous fistula (and in certain other cases 
of widespread fistula) it has been our practice, after the operation, 
to suture the sphincter and rectal wall and to pack the rest of the wound. 
This can be done only in those cases where the length of the skin incision 
is much greater than the depth of the wound, so that the wound may be 
packed widely open and allowed to heal from the bottom. In one 
case treated in this manner and under continuous observation for two 



PROLAPSE OF THE RECTUM 465 

years there has been no recurrence. Tuberculin may be useful in 
carefully selected cases of tuberculosis of this region. It should not 
be used in the presence of lesion of the lung. 

PROLAPSE OF THE RECTUM. 

This condition may be acute or chronic. The acute type is seen in 
babies and young children, but it may occur at any age. Chronic 
prolapse is more common in adults. Constipation, diarrhea, or any 
other factor which leads to severe straining during defecation, may 
cause prolapse. The milder cases show a protrusion of the mucous 
membrane alone; while the severer cases show a prolapse of the entire 
thickness of the rectum. At first the prolapse is easily reduced; but 
in the more chronic cases the prolapse becomes irreducible and may 
even become strangulated. Hemorrhoids, ulceration, polypi, and 




Fig. 355. — Prolapse of rectum. (Ashhurst.) 

intestinal parasites (threadworms), may act as exciting causes. The 
condition is, in reality, a hernia of the rectum through the anus and 
should be treated as such. The diagnosis is usually apparent on 
inspection. The protruding mass, covered with mucous membrane 
and showing a dimple at the end, can hardly be mistaken for any other 
affection. Occasionally a case of intussusception presents itself in 
which there is a large mass protruding from the rectum which resembles 
prolapse. The history and digital examination of the rectum serve to 
differentiate these two conditions. 

For purposes of description, prolapse of the rectum has been divided 
into two varieties, the complete and the incomplete. In the incom- 
plete variety only the mucous membrane is protruded; while in the 
complete, the protrusion consists of the entire thickness of the rectum. 
In beginning cases the prolapse tends to reduce itself spontaneously; 
but in more advanced cases the protrusion is more or less permanent 
and the exposed surface becomes inflamed and ulcerated. When 
30 



466 AFFECTIONS OF THE RECTUM AND ANUS 

strangulation occurs, the protruded mass becomes swollen and purple. 
Unless relieved, gangrene and sloughing may occur. 

In making the diagnosis of prolapse of the rectum it should be 
remembered that in women who have had severe perineal tears there 
may be a bulging of the anal region which simulates prolapse. 
Abscesses of the prostate or pelvis may point toward the rectum, 
causing a protrusion of the anterior wall of the -rectum through the 
anus. A true hernia of this region may occur, the sac containing the 
sigmoid, cecum, small intestine, or any of the pelvic organs. 

Treatment. — In acute cases and chronic cases of the first degree 
palliative treatment is indicated. Straining at stool should be abso- 
lutely forbidden, the patient's bowels being regulated by mild 
cathartics. If any causative factor can be found, it should receive 
proper treatment. Hemorrhoids should be excised, polypi should be 
removed, and phimosis, vesical calculi, and pinworms should receive 
appropriate treatment. The patient should be warned that even 
should extreme constipation occur, he must not under any condition 
strain while at stool. In such cases a small daily enema may be 
required in order to start evacuation of the bowels. The patient must 
be taught to replace the prolapse and to hold the buttocks together 
during defecation. In children after the prolapse has been reduced 
the buttocks should be firmly strapped together with adhesive plaster, 
which is left on during defecation and removed only when soiled or 
when bathing the child. The mother or nurse is taught to apply this 
strapping so that it may be replaced when soiled. If this procedure is 
carefully carried out, the tendency to prolapse in children will usually 
disappear. To increase the muscular tone local hypodermic injections 
of large doses of strychnine (grains -£-$ to ■%>$) and a daily enema of cold 
water have been advised. In adults, a cone-shaped pad may be placed 
over the anus and pressure made by a properly fitted belt, which will 
effectually prevent prolapse while the patient is up and about. 

In some cases the prolapse becomes strangulated, and if neglected 
soon becomes congested and edematous. Gangrene may result, with 
sloughing of the prolapsed portion of the bowel. 

Taxis of acute prolapse of the rectum is accomplished by placing 
the patient in the knee-chest position and after preliminary steady 
pressure on the prolapse to reduce the edema, the finger is inserted in 
the rectum and the prolapsed rectum is slowly forced back through 
the sphincter. Care must be exercised not to withdraw the finger too 
quickly or the prolapse will recur. Preliminary application of cocain 
and adrenalin will cause constriction of the vessels and aid reduction. 
After reduction, a stringent enemata may be used. In every case it is 
important to bear in mind the possibility of mistaking a case of intus- 
susception for a prolapsed rectum. The conditions may be differ- 
entiated after the protruding mass has been reduced. In cases of 
prolapse the mass will be greatly decreased in size or entirely disappear 
after reduction; while in intussusception, the mass which feels like a 
soft, partially-dilated cervix uteri will persist within the rectum. 



POLYPUS OF THE RECTUM 467 

In recurrent prolapse the bowel may be cauterized with carbolic 
acid or the actual cautery. If the cautery is used, the bowel may be 
cauterized in longitudinal lines, usually four or five, before reduction. 
If the prolapse is not too large it is much better to reduce the prolapse 
first, and then after dilating the sphincter cauterize the bowel from 
within. Three deep linear burns are made starting from above the 
prolapsed portion of the bowel and extending downward to the margin 
of the skin. The burns should be deep enough to cause adhesions 
between the mucous membrane and the deep wall of the rectum. 
After this operation the patient should be kept in bed with the foot of 
the bed elevated for ten days. During the first five days the buttocks 
should be strapped together so as to prevent any tendency to pro- 
trusion and the bowels should be kept constipated with opium. A 
support may be used to prevent prolapse during sleep. Defecation 
should take place while in the horizontal position. The local reaction 
which follows this method of treatment acts in two ways. It causes 
(1) constriction and stiffness of the wall of the gut, and (2) adhesions 
between the rectum and the structures in the pelvis. After the 
patient is up and about, a support should be worn for several months 
and the ordinary palliative treatment should be carefully carried out. 
Often these measures will not effect a cure. In such cases a radical 
operation is required. Laparotomy, with fixation of the sigmoid 
to the abdominal wall or obliteration of the pelvic peritoneal pouch 
of Douglas, or in some cases amputation of the prolapse, have all been 
advised and may be followed by excellent results in selected cases. 

POLYPUS OF THE RECTUM. 

Small tumors of the rectum, originating as papillomata or fibromata, 
may become pedunculated and protrude from the rectum. The 
surface may show papillomatous change or may be covered with 
normal mucous membrane. Ulceration is not uncommon. They 
usually give no symptoms unless prolapsed through the anus; but, if 
the tumor is large, it may cause a sensation similar to the desire to 
defecate. As a result the patient sits and strains at stool, possibly 
causing a complete prolapse. In cases where the polypus is forced 
through the anus and the pedicle is constricted by the sphincter, the 
tumor becomes swollen, edematous, and acutely painful. As these 
tumors are usually very vascular, ulceration of the surface may be 
followed by profuse hemorrhage. The history resembles that of 
hemorrhoids, but examination readily differentiates the two conditions. 

Treatment.— A polypus of the rectum should always be removed 
by operation. Aside from the symptoms due to the growth itself, the 
possibility of a secondary prolapse of the rectum should be borne in 
mind. After the rectum has been well cleansed, a speculum is inserted 
and the pedicle is ligated as close to the wall of the rectum as possible. 
The growth is then cut away and the stump cauterized with pure 



468 



AFFECTIONS OF THE RECTUM AND ANUS 



carbolic acid. The after-treatment is the same as for hemorrhoids. 
This operation can usually be done under local anesthesia with little 
or no pain. 

If the polypus is large with a broad base it may be necessary to give 
a general anesthetic and dilate the sphincter muscle dividing the 
mucous membrane at the base of the pedicle by a circular incision and 
then cutting the pedicle through, care being taken to clamp and tie 
the larger vessels. The mucous membrane should be then sutured 
with silk or linen and the bowels kept constipated for several days. 
Complications are rare. 

ULCERS OF THE RECTUM AND ANUS. 

Chronic ulceration may result from infection of a wound or abrasion, 
or from the continuous pressure of fecal masses in poorly-nourished 




Fig. 356. — Small tuberculous ulcers about the anus. 

individuals. Chancroidal ulceration is occasionally seen about the 
region of the anus, either as a simple lesion or as reinfection from the 
genitalia. Secondary syphilis, in the form of mucous patches or 
condylomata, is not infrequent; but chancre and tertiary ulcers are 
comparatively rare. On account of the infectious character of the fecal 
material which passes over the surface, healing of ulceration in this 
region is likely to be greatly delayed. Ulceration of the anus is fre- 
quently due to a fissure. 

In ulcer of the rectum, pain, diarrhea, tenesmus, and the passage 
of muco-pus and blood, are likely to be the prominent symptoms. 
Ulcers about the anus and external skin are associated with little or 
no pain except during defecation. In patients giving the history of 
chronic diarrhea associated with a mucopurulent or bloody discharge, 
a thorough proctoscopic examination should be made. Ulceration may 



ULCERS OF THE RECTUM AND ANUS 



469 



exist as part of malignant disease or tuberculosis. Multiple ulcers 
are not uncommon. 

Treatment. —The bowels should be moved frequently, constipation 
being avoided by the use of mild cathartics. Regular doses of mineral 
oil keep the feces soft and avoid the irritation caused by hard fecal 
masses. The rectum should be cleansed several times daily with a 
warm solution of boric acid (about 1 per cent) applied internally in the 
form of an enema, and externally as a wash about the anus. The 
ulcerating surface may be touched with carbolic acid, silver nitrate, 
argyrol, or some other antiseptic. Ichthyol suppositories or ointment 
applied directly to the ulcer will often hasten healing. 

When the ulcer is situated externally, thorough attention to cleanli- 
ness and the application of antiseptic ointments, such as blue ointment 
or carbolic acid ointment, will often effect a cure except in cases of 
ulceration due to a fissure which is resistant to treatment. Some cases do 




Fig. 357. — Syphilis of the rectum. 



well when carefully cleansed and kept dry with a dusting powder, such 
as bismuth subgallate or aristol. Calomel and talcum, equal parts, 
make a most satisfactory powder for use about the rectum or genitals. 
The general condition of the patient should receive attention, tonic 
and dietetic treatment being given to build up the general health. 
Syphilis, if present, should receive appropriate general treatment, 
even if the ulcers are not characteristically syphilitic. On the other 
hand, when the ulcers are definitely syphilitic, the local treatment 
should be carried out painstakingly as an adjunct to the antisyphilitic 
treatment. In some cases the ulcers may become sluggish and indu- 
rated and healing may be protracted. Curettage or excision of the 
ulcer is sometimes necessary to accomplish a cure in such cases. The 
operation may be done under local anesthesia, either with or without 
dilatation of the sphincter. Curettage, performed after preliminary 
preparation as in the operation for hemorrhoids, consists of scraping 



470 



AFFECTIONS OF THE RECTUM AND ANUS 



the sluggish granulations away with a sharp curette and touching the 
base with pure carbolic acid. Excision may be performed under local 
or general anesthesia, care being taken to excise the entire ulcer. The 
wound is not sutured but is allowed to heal by granulation, the patient 
being kept in bed for about two weeks if the operation has been exten- 
sive. 

COCCYGEAL CYSTS. 

This cysts develop between the folds of the buttocks just over the 
coccyx. At birth they usually show as a dimple, but the depression 
may be deep enough to form a sinus or cyst, which becomes filled with 
sebaceous material and may contain hair. Frequently these cysts are 
unnoticed until adult life, when they are likely to become infected and 
painful. On examination only a small opening may be visible just 




Fig. 358. — Coccygeal cyst, infected. Probe in sinus does not enter cyst. 

posterior to the anus. This may be mistaken for the external opening 
of an anal fistula. If a probe is passed into the sinus, it will be found 
to pass posterior to the coccyx; while in an anal fistula the sinus passes 
toward the rectum. In other cases no opening is visible but there is a 
fluctuating tumor near the coccyx. 

Treatment.— The sinus or cyst should be removed completely by 
means of a median incision. Following this, the wound is packed 
and allowed to heal by granulation. If suture is attempted, a 
secondary fistula is almost certain to occur. 

Dermoid cysts occur in the same location and should be treated in 
the same manner. 



MALIGNANT TUMORS OF THE RECTUM AND ANUS. 

In the region of the anus small superficial epitheliomata may occur, 
having the appearance of small flattened tumors with fissured surfaces. 



MALIGNANT TUMORS OF RECTUM AND ANUS 



471 



As a precaution, any small tumor about the rectum, the character of 
which is undetermined, should be removed and examined micro- 
scopically. In the rectum, carcinoma is of frequent occurrence. If 
every case giving a history of rectal hemorrhage is carefully examined, 
there will be more carcinoma found in the operable period. Operation 
after the condition has become serious enough to cause stricture of the 
rectum can accomplish little. 




Fig. 359. — Carcinoma of the rectum, recurrent. 




Fig. 360. — Large sarcoma on a two-year-old child noticed shortly after birth. 

Proctoscopic examination is indicated in every case of persistent 
rectal hemorrhage. In doubtful cases, a portion of the tumor should 
be removed for microscopic examination. If cancer is found, radical 
operation should be performed as soon as possible. While cancer of 
the rectum has a very high mortality, this is due to a large extent to the 
fact that most rectal cancers are inoperable before they are seen by 
the surgeon. If the general practitioner and the casual surgeon will 
examine rectal cases more carefully, the percentage of operable cases 
referred to the surgeon will be greatly increased. 



CHAPTER XVIII. 

AFFECTIONS OF THE EXTERNAL GENITALS OF THE 

MALE. 

INJURIES. 

Wounds of the Penis.— The genitalia are protected by their location 
and wounds are comparatively rare. Lacerated wounds, seen after 
falls upon sharp objects, are the commonest type. When the penis 
is erect at the time of the injury there will be profuse hemorrhage, 
but when it is flaccid there is often very little bleeding. 

Treatment.— Wounds of the penis should be cleansed in the same 
manner as other wounds and sutured with fine silk. If there is a loose 
flap of skin an attempt should be made to attain primary union, for 
a large scar is apt to result in troublesome contractures. Hemorrhage 
from the corpora cavernosa is apt to be profuse and can be controlled 
only by accurate suture of its fibrous sheath. If the urethra is wounded 
the edges should be brought into accurate apposition with small buried 
catgut sutures, the knots being tied outside the canal. Even after 
accurate suture of the urethra, a stricture may occur. It should be 
guarded against by passing sounds at two- or three-day intervals, 
beginning about the fifth day with a small-sized sound and gradually 
increasing the size. Owing to the fact that the genitalia have a better 
blood supply than most other parts of the body, suppuration is com- 
paratively uncommon. 

When the penis has been injured it is well to keep the patient under 
the influence of morphine and bromides in order to prevent erections 
which would seriously interfere with healing. 

Wounds of the Testicle.— Wounds of the testicle may be accidental 
or they may complicate the operative puncture for hydrocele. In this 
condition there is bleeding into the tunica vaginalis and hematocele 
results. There are no special precautions necessary in the suture of 
scrotal wounds except accurate approximation of the loose skin. 

Contusions of the Penis and Testicles.— These occur commonly 
either from blows or kicks accidentally received while at work, or in 
athletic contests, or falling astride hard objects. They may be followed 
by severe shock which is out of all proportion to the injury received. 
Owing to the looseness of the tissues there are apt to be considerable 
swelling and edema. Ecchymosis is early and is liable to extend over 
a wide area sometimes involving the entire scrotum and penis and 
extending onto the thigh. Severe injury may cause rupture of the 
urethra or hematocele. The injured testicle may swell to several 



FRACTURE OF THE PENIS 473 

times its normal size and there may be extensive hemorrhage into the 
tunica vaginalis. Dislocation of the testicle beneath the skin of the 
thigh or abdomen has been reported. 

Treatment.— In uncomplicated cases the patient should be put to 
bed with the penis and scrotum elevated by means of a broad adhesive- 
plaster bridge stretched across the thighs. Cooling wet dressings or 
an ice-cap help to relieve the pain. In some cases subcutaneous 
bleeding is so great that incision and suture of the corpora cavernosa 
are indicated. Ordinarily a few days' rest in bed is all that is required. 
A suspensory bandage serves as a support after the patient leaves his 
bed. In some cases after contusion of the testicle, pain and swelling 
persist for a long time. 

Hematoma. —The loose tissue of the penis and scrotum allows blood 
to spread rapidly in the same manner as the loose tissue about the eyes. 
After an injury, the entire penis and scrotum may become dark blue 
from subcutaneous extravasation of blood. The absorption of the 
extravasated blood is usually rapid and complete because of the ex- 
cellent blood supply of these parts. Occasionally, however, the blood 
may collect at one point, forming a hematoma. When this occurs it 
should be treated in the same manner as a subcutaneous hematoma 
occurring elsewhere. Usually it is better to treat it conservatively, 
but occasionally a large hematoma causes so much pain that early 
incision with ligature of the bleeding point is indicated. 

Hematocele.— If the bleeding takes place into the tunica vaginalis 
or into a hydrocele sac, the condition is known as hematocele. In 
this condition absorption is likely to be slow and operation with removal 
of the coagulated blood is almost always required. The sac should be 
aspirated about the third day with a syringe and a fairly large needle. 
If large clots prevent complete aspiration, an incision about half an 
inch long should be made passing through the skin and the sac wall, 
and the clots expressed. Following this, the wound should be sutured 
with fine silk without drainage. If the operation is carried out under 
strict aseptic conditions there is practically no danger of infection. 

After the operation the patient is kept in bed for twenty-four hours, 
with pressure applied by means of a snug-fitting T-binder. A sus- 
pensory support should be worn for several weeks. 

Fracture of the Penis.— As a result of violent efforts at coitus and 
following contusions, especially when the penis is in the state of erection, 
one or both of the corpora cavernosa may be ruptured. The result 
is a free escape of blood into the subcutaneous tissues so that the penis 
is markedly swollen throughout its whole extent. Untreated cases 
show an incomplete erection, the distal portion remaining flaccid or 
incompletely erect. Nervous reflex symptoms may result. 

Treatment.— Conservative treatment is unsatisfactory. The penis 
should be constricted at its base with a ligature and the rupture 
exposed under local anesthesia. A longitudinal incision is made down 
to the corpus cavernosum, the superficial clots are expressed, and all 



474 AFFECTIONS OF EXTERNAL GENITALS OF MALE 

bleeding points ligated. At this stage it is well to loosen slightly the 
ligature about the penis so as to locate the points of hemorrhage. 
Ordinarily no large bleeding vessels can be detected, the blood coming 
from the spongy erectile tissue. The sheath of the corpus cavernosum 
should be carefully approximated and sutured with fine chromic 
sutures, the sutures being placed close together so that hemorrhage 
cannot occur between the stitches. The skin is now sutured with 
horsehair or silk and a circular bandage applied after the removal of the 
ligature. For several days after the operation the patient should be 
kept under the influence of morphine and bromides to prevent erection, 
which is apt to result in subcutaneous hemorrhage. Ordinarily no 
drainage is required, but if the clots beneath the skin recur they should 
be expressed through a small opening made in the line of skin sutures. 
Catheterization may be necessary during the first few days, and 
sounds should be passed at weekly intervals for several months to 
prevent stricture. Suppuration following operation upon the penis 
is a rare complication. 

RUPTURE OF THE URETHRA. 

The urethra may be wholly or partially divided either by wounds or 
by blows upon the penis or perineum. A common cause is a fall astride 
a board or other hard object. If there is an external wound the cut 
ends of the urethra can be seen ; but if the skin is intact and the rupture 
is partial, hemorrhage from the meatus may be the only symptom. 
In a complete rupture without superficial laceration of the skin, there 
may be retention of urine associated with a certain amount of extravasa- 
tion. In severe cases the proximal end of the urethra retracts and a 
sound cannot be made to enter the bladder. In milder cases there may 
be simply pain and slight hemorrhage from the meatus. The diagnosis 
is made by direct examination of the urethra with the endoscope. 

Treatment.— In mild cases without an external wound, in which the 
only symptoms are slight swelling and bleeding from the meatus, the 
condition may be treated conservatively. L rotropin should be given 
as a prophylactic against infection and cold applications should be 
applied externally for the relief of pain. As healing progresses, sounds 
should be passed to prevent stricture. 

In cases associated with an external wound, the urethra should be 
accurately sutured. Often the skin sutures can be so arranged as to 
pass down nearly to the mucous membrane, the edges of which will be 
approximated when the skin sutures are tied. If this is not practicable 
a few buried sutures of fine chromic catgut may be used. If the 
urethra has been so injured that the edges cannot be brought together, 
it should be loosened for about an inch in each direction after which 
the edges can usually be easily approximated. This operation may be 
performed under local anesthesia. When the rupture is extensive or 
complete without an external wound it is better to operate under gen- 



FOREIGN BODIES IN THE PENIS 475 

eral anesthesia. In complete rupture the operation is practically an 
external urethrotomy without a guide. The patient is placed in the 
lithotomy position and a grooved sound is introduced as far as possible. 
This serves as a guide for the incision, which should be made on the 
under surface of the penis in the mid-line. The distal portion of the 
urethra is easily located and in recent cases the extravastion of blood 
directs attention to the proximal portion. The torn ends are carefully 
sutured together with fine catgut. If this is found difficult, a No. 16 
French soft rubber catheter may be inserted through the penile urethra 
into the bladder and the urethra sutured over this. The skin is then 
sutured with fine silk. If a urinary fistula occurs, it usually closes 
spontaneously after a few weeks. 

In the operative treatment of division of the urethra, a catheter 
should be left in place for four or five days after operation and the 
patient should be given regular doses of urotropin to prevent cystitis. 
After healing is complete, sounds should be passed at intervals of three 
or four days for several months to prevent stricture. 

FOREIGN BODIES IN THE PENIS. 

Foreign bodies may be passed into the urethra by children or by 
adults for purposes of sexual excitement. Occasionally, part of a 
catheter or a similar object has slipped into the urethra during the 
treatment of urethritis. Foreign bodies may cause no symptoms unless 
they are sharp or become encrusted with urinary salts, when they may 
set up an irritation which leads to urethral and periurethral infection. 

Treatment. —The removal of a foreign body from the urethra may be 
extremely difficult. Before and during manipulation the penis should 
be grasped near the base to prevent the object from slipping into the 
bladder. Having located the object it is best to introduce and endo- 
scope into the penis and to attempt to grasp the object with a small 
alligator forceps. If there is no endoscope at hand, there are several 
other methods which may be tried. 

The simplest method is to give the patient several glasses of water 
to drink and after the bladder is well filled have him lean forward so 
that the penis is directed downward. The end of the penis is pressed 
together while the patient attempts to urinate. This causes the urine 
to remain in the urethra, dilating it. The pressure at the meatus is 
now suddenly released and the urine comes out with a spurt carrying 
the foreign body along with it. In other cases if the object is smooth 
it may be worked forward in the same manner as a bodkin is passed 
along a fold of cloth. If these methods fail, the foreign body should 
be exposed by a longitudinal incision in the mid-line on the under sur- 
face of the penis. After its removal, unless infection is present, the 
incision in the urethra should be sutured in the same manner as in 
rupture of the urethra. 

Ordinary pins may often be removed by the urethroscope. They 



476 AFFECTIONS OF EXTERNAL GENITALS OF MALE 

are usually introduced head first so that the point becomes engaged 
during removal. If this condition occurs, the point of the pin should 
be forced through the skin and the direction of the pin reversed. When 
hairpins are found the points are almost always directed toward the 
end of the penis. If the points are squeezed together they may 
possibly be made to engage in the end of the urethroscope. If this 
fails, the points may be forced through the skin and the pin removed 
after cutting off one of the projecting ends. 

PARAPHIMOSIS. 

In some men the normal foreskin is so tight that it cannot readily 
be drawn back over the glans penis. In such cases if the foreskin is 
drawn back over the glans penis and allowed to remain in this position, 
swelling of the glans may make it difficult or impossible to return the 
foreskin to its normal position. The head of the penis is swollen and 
the foreskin becomes edematous forming a cylindrical collar about the 
corona. The longer this condition persists, the greater the swelling 
and the tighter the constriction. If untreated, spontaneous reduction 
rarely occurs and the foreskin usually becomes adherent to the glans 
in the retracted position. Gangrene of the glans or foreskin may occur 
as an infrequent complication. 

Treatment.— To reduce a paraphimosis the thumbs of both hands 
are placed upon the head of the penis and the index and middle fingers 
are placed above the edematous foreskin, the index fingers being on 
the dorsal surface and the middle fingers on the ventral. Steady 
pressure is made upon the glans, the object being to compress it and 
thus reduce the edema. After this has been continued for about ten 
minutes, an attempt is made to force the head through the opening in 
the foreskin. If this is not successful, further pressure is made upon 
the head. The disappearance of the edema can sometimes be accom- 
plished by the application of a rubber bandage, which is left in place 
for from twenty to thirty minutes. 

If the above procedure fails, a grooved director should be slipped 
beneath the constricting edge of the foreskin and a dorsal incision made 
in the mid-line. This always relieves the constriction and permits the 
glans to be reduced. The dorsal slit is now sutured, the line of sutures 
connecting the skin and mucous membrane but leaving the slit in the 
foreskin open. If desired, circumcision may be performed at this time. 

RETENTION OF URINE. 

In some cases, due to accidental injury or to an old stricture, there is 
retention of urine which cannot be relieved by catheterization. The 
bladder can be palpated extending well up into the abdomen occasion- 
ally reaching as high as the umbilicus. When catheterization is 
impossible, voluntary urination may take place if the patient is placed 



BURNS OF THE EXTERNAL GENITALIA 477 

in a warm bath and given a hypodermic of morphine. If this is not 
successful, the bladder should be aspirated. Forcible attempts to 
introduce a non-flexible catheter, such as a silver catheter, are seldom 
successful and usually only result in increasing trauma to the tissues. 

Aspiration of the bladder is performed with a small trocar and cannula, 
not larger than a No. 14 French catheter. After determining by per- 
cussion that the bladder is distended well above the pubis, the skin is 
cleaned as for a surgical operation, and the trocar is plunged directly 
into the bladder in the mid-line at a point about one inch above the 
symphysis. There is no danger of entering the peritoneal cavity, 
for the distended bladder has carried the peritoneum several inches 
above the pubis. The trocar is removed leaving the cannula in place, 
and the urine is allowed to run out. No suction is required. If the 
distention has been considerable it is better not to withdraw all urine 
as hematuria and collapse may follow. Roughly, about two-thirds 
may be removed. The cannula is now withdrawn and the wound 
sealed with a little collodion. As a preliminary step, a small puncture 
may be made in the skin with the point of a sharp knife under local 
anesthesia. This makes the introduction of the cannula much easier 
and less painful. 

After the relief of the retention, the ability to urinate may return; 
or due to the lessened congestion of the parts it may be possible to pass 
a catheter. 

If the retention recurs, an internal or external urethrotomy should 
be performed. These operations are major and are well described in 
works on major surgery. 

BURNS OF THE EXTERNAL GENITALIA 

Burns of the external genitalia are similar to burns on other parts 
of the body except that burns of the penis are liable to be associated 
with a high degree of edema. They should be treated with mild 
ointments which usually bring about healing with little suppuration. 
The edema subsides in a few days. Chemical burns are sometimes 
seen after the use of too strong antiseptics in prophylaxis against 
venereal disease. In a case recently under treatment, there was a 
severe bichloride of mercury burn of the glans and an acute traumatic 
urethritis as a result of the application of a solution of 15 grains of 
bichloride of mercury dissolved in a few ounces of water and injected 
as a prophylactic. Such a urethritis lasts many months and is very 
resistant to treatment. 

Mustard gas burns about the penis and scrotum were very common 
during the recent war. They occur first as an area of erythema which 
appears about twenty-four hours after exposure to mustard gas. The 
stage of erythema is followed by vesication and ulceration. Many 
of these cases have been seen a year or more after apparent recovery 
complaining of irritation of the cicatricial areas on the scrotum. On 



478 AFFECTIONS OF EXTERNAL GENITALS OF MALE 

examination the skin appears reddened and hypersensitive. It is 
probable that such late results are in the nature of an intertrigo to 
which the skin is more susceptible because of loss of vascular tone. 
The condition can be temporarily relieved by the use of a bland dusting 
powder, but it is liable to recur. 



DISEASES OF THE MALE EXTERNAL GENITALIA. 

Balanitis.— Inflammation of the inner surface of the prepuce and the 
mucous membrane of the head of the penis is known as balanitis. 
It is commonly seen in a mild degree following uncleanliness. In 
patients with a long foreskin which cannot be retracted the secretions 
accumulate, and as a consequence, irritation and a mild degree of 
inflammation may result. Balanitis is increased by, and often associ- 
ated, with glycosuria. It is almost constantly present in acute 
urethritis and in ulcerative diseases of the head of the penis. 

Treatment.— In the simplest cases, cleanliness and the application 
of a bland dusting powder are all that is necessary. The foreskin 
should be retracted and the penis well bathed with soap and water and 
rinsed in clear water. The parts are now well dried, care being taken 
not to rub the inflamed mucous membrane. If the penis is dusted 
with any simple powder such as talcum or bismuth and the foreskin 
allowed to slip back over the head, the opposed surfaces will be kept 
separated and perfectly dry. This treatment should be repeated by 
the patient night and morning. Ointments have been used, but owing 
to their tendency to macerate the skin, they give less satisfactory 
results. In severer cases, especially those in which the foreskin cannot 
be retracted, circumcision should be done. It is hardly necessary to 
state that if diabetes, urethritis, or any other causative factor, can be 
found it should receive appropriate treatment. 

Herpes Genitalis.— This condition occurs fairly frequently on the 
genitals. It may be associated with herpes of the groin or lower part 
of the trunk. On the genitals the epithelial covering of the blisters 
is apt to be rubbed away, small ulcers each surrounded by a small area 
of inflammation, resulting. Herpes may be differentiated from other 
ulcerative lesions by the history of neuralgic pain preceding the ulcers 
for several days, by the multiplicity of the lesions, and the vesicular 
eruption when present. 

Treatment. —The treatment is the same as for herpes zoster in other 
parts of the body, except that special care must be taken to keep the 
surfaces dry and free from irritation. Recurrent cases are common 
and may frequently be cured by circumcision. In certain resistant 
cases we have seen the ulcers cured by treatment with blue ointment. 
This is the only exception to the general rule that ointments should 
not be used in herpes, and the success in these cases was probably due 
to the fact that it is ordinarily very difficult to keep these surfaces dry. 



DISEASES OF THE MALE EXTERNAL GENITALIA 479 

Edema of the Penis.— This condition is usually limited to the pre- 
puce, but it may involve the entire organ. It occurs as a result of 
injury, as an accompaniment of a venereal disease, and when the cir- 
culation of the penis has been interfered with, as by constriction 
due to paraphimosis, tight bandages, etc. It occasionally occurs 
without apparent cause. The organ may be SAvollen two or three 
times its normal size, the edema involving chiefly the subcutaneous 
tissue. The skin has a characteristic pinkish translucent appearance. 
Chronic edema occurs in elephantiasis, true elephantiasis is seldom 
seen except in tropical countries. 

Treatment. —The underlying cause should be removed and the patient 
should be put to bed with the penis held elevated upon an adhesive- 
plaster bridge. Usually the edema subsides in a few days. In pro- 
tracted cases, multiple punctures may be required. 

Preputial Calculi.— Preputial calculi usually occur in adults who 
suffer from phimosis. The irritation causes a purulent discharge 
occasionally associated with pain. They originate generally from the 
impregnation of masses of smegma with lime salts. Occasionally 
they may be secondary to calculi formed in the kidney or bladder and 
arrested in the cavity of the prepuce. 

Treatment. —The treatment is removal by operation. A dorsal slit 
is made under local anesthesia and the prepuce is retracted. If 
inflammation is not marked, circumcision may be performed, but if 
there is considerable purulent discharge it is better to perform the 
operation after the inflammation has subsided. 

Adhesions of the Prepuce.— In children, and occasionally in adults, 
the foreskin, if not regularly retracted, becomes adherent to the glans 
by more or less firm adhesions. Smegma continues to be secreted 
about the corona and remains in the form of an inspissated mass. 
Occasionally the smegma ferments causing balanitis. 

Treatment.— If the opening of the foreskin is too small to slip over 
the glans a circumcision or a dorsal slit must be performed. In most 
cases however, especially in children, the foreskin is merely adherent 
and can be partially retracted. After having retracted it as far as 
possible, the end of a probe is slipped between the foreskin and the 
penis and passed around the glans breaking up the adhesions. If 
this is impossible, the retraction may be accomplished by manipulation 
with a piece of gauze held between the thumb and fingers. The 
mistake usually made is to stop before the corona is fully exposed. 
The operation should be done in a good light and the entire corona 
should be exposed. As the operation, with a little dexterity, can be 
accomplished in a minute or less, an anesthetic is rarely required. 
After the prepuce has been retracted, the penis should be washed with 
soap and water and vaseline should be smeared on the glans to prevent 
recurrence of the adhesions. The prepuce should be retracted daily 
until healing is complete, 



480 



AFFECTIONS OF EXTERNAL GENITALS OF MALE 



Abscess.— An abscess about the external genitals may occur as an 
infection about a hair follicle or it may be secondary to inflammation 
of the epididymis or testicle. In any case of apparently spontaneous 
infection about the genitalia, the pubic region should be carefully 
searched for evidences of pediculosis. Abscesses about the genitalia 
should be treated in the same manner as those occurring in other parts 
of the body. In many cases abscesses are secondary to extravasation 
of urine due to an old stricture. Periurethral abscesses frequently 
complicate gonorrhea. 

Urethritis.— Inflammation of the urethra may be due to infection 
with the gonococcus or some other organism. Simple urethritis is 
distinguished from gonorrheal by the character of the discharge, the 
chronicity of the disease, the history, and the absence of gonococci 

from the discharge. There is usually a 
little redness about the meatus, and pus 
can be expressed by light pressure on the 
urethra. In every case of discharge from 
the penis, unless the diagnosis can be 
positively made to the contrary, gonor- 
rhea should be suspected and the condition 
should be treated as such. After the 
differential diagnosis is made by the ex- 
amination of a smear the case should 
receive appropriate treatment. A not 
infrequent cause of simple urethritis is 
foreign bodies in the urethra. This con- 
dition has already been described. A 
chemical urethritis, actually a chemical 
burn, may follow the use of strong irri- 
tants in prophylactic treatment or in the 
treatment of gonorrhea. We have seen 
an urethral discharge kept up for months 
through self-injections by a patient who, 
after exposure, feared infection and believed the discharge that was 
due to the chemical irritant to be gonorrheal in character. In like 
manner physicians sometimes actually prolong the chronic stage of 
urethritis through intra-urethral applications and manipulations. 

Venereal Prophylaxis.— A patient often requests advice regarding 
the dangers of infection following an exposure several days before. In 
such a case there is nothing that can be done which will have much 
influence toward preventing the development of venereal disease. 
Venereal prophylaxis during the first few hours has however given 
excellent results. If a (10 per cent) argyrol solution is injected into 
the urethra within a few hours after exposure to gonorrhea, it acts as a 
powerful prophylactic against infection. The longer the period after 
exposure the less is the value of the injection as a preventative. The 
argyrol should be held in the urethra. In addition, a calomel ointment 




Fig. 361. — Inguinal adenitis 
(bubo) chancroid on foreskin, 
eight days' duration. 



DISEASES OF THE MALE EXTERNAL GENITALIA 



481 



(50 per cent) should be well-smeared about the prepuce and glans. It 
is advisable to apply such treatment to any patient presenting himself 
within twenty-four hours after exposure. This plan was used exten- 
sively in the U. S. Army during the recent war. Apparently it greatly 
reduced the incidence of venereal disease. 




Fig. 362. — Gonorrheal arthritis of the right sternoclavicular joint, two months after 

urethritis. 




Fig. 363.— Gonorrheal epididymitis on right, with enlarged inguinal nodes on left. 

Epididymitis.— Epididymitis usually follows urethral infection, but 
it may also result from an injury, such as a blow or a kick. In some 
cases it is seen as a metastatic condition in smallpox or pyemia. 
It follows gonorrhea in about 20 per cent of the cases, but it may com- 
plicate cystitis or urethritis of non-specific origin. 
31 



482 AFFECTIONS OF EXTERNAL GENITALS OF MALE 

The epididymis is felt as a large indurated mass in which the testicle 
is embedded. The vas deferens is apt to be inflamed and contain pus. 
Usually, during the height of the disease, there are marked general 
symptoms with fever up to 102° or 103° F. Ordinarily, only one side 
is involved. The acute period lasts from about six to ten days and 
then gradually subsides in from three to six weeks, usually leaving a 
small hard nodule at the site of the epididymis. Stricture of the vas 
deferens upon the affected side ordinarily results from the inflammation 
of the epididymis. Consequently, sterility usually follows when both 
sides have been involved. 

Treatment.— In the early stage the patient should always be confined 
to bed with the testicles supported. Any local treatment of the 
urethra is contraindicated. If urethral injections are being given, they 
should be stopped at once. General measures are taken for the relief 
of the febrile symptoms and the patient is given large quantities of 
water to flush out the urethra. Morphine may be required for the 
acute pain. 

The testicle may be supported either by a folded towel arranged as a 
sling or by means of a triangular bandage so arranged that the base 
passes transversely across posterior to the scrotum and the ends are 
drawn up together in the mid-line forming a sling. The apex is now 
drawn upward over the penis and attached together with the ends of 
the bandage to a waistband. If desired a hole may be cut in the 
bandage allowing the penis to protrude. Another method is to pass 
a wide strip of adhesive plaster across the thighs just below the scrotum. 
This is stretched tightly and is known as a bridge; the scrotum and 
testicles rest on the central portion. 

Applications of a cooling wet dressing, such as dilute alcohol, or 
witch hazel, or the Use of an ice-cap relieve the pain during the first 
twenty-four hours. In a few cases hot fomentations seem to act 
better than cold. However, heat is ordinarily more valuable as an aid 
to resolution after the acute stage has passed. 

Ichthyol ointment, guaiacol (5 per cent) in glycerin, and belladonna 
ointment, have been recommended as local applications. When the 
patient is able to be up and about, the testicles should be supported 
with a suspensory bandage for several weeks or longer. Operation 
may be required in chronic cases. It has been advised as a routine 
treatment for acute epididymitis. (See below.) 

Epididymotomy.— This operation is indicated when there is a large 
abscess of the epididymis. The abscess should be punctured at the 
most prominent part, usually posteriorly. The incision should be 
located so as not to injure the vessels which run on the inner side of 
the epididymis. Hagner 1 has advised operation in all cases of acute epi- 
didymitis. This gives almost immediate relief from pain, the patient 
ordinarily being confined to bed for about a week, Hagner claims that 

* Annals of Surgery, December, 1908, 



DISEASES OF THE MALE EXTERNAL GENITALIA 



483 



sterility is less likely to follow than in non-operative cases. An incision 
is made over the lateral surface of the testicle down to and through 
the tunica vaginalis. The enlarged epididymis is then forced up into 
the wound. The infiltrated area of the epididymis show as prominent 
nodules. These are punctured with the point of a sharp knife which 
cuts only the serous covering and the sheath of the epididymis, care 
being taken not to injure the vas. A blunt probe is then inserted into 
each puncture and by blunt dissection forced down into the small 
abscess-cavity. When it enters the cavity the pus escapes along the 
probe. Several punctures should be made to relieve the tension. 
Drainage may be secured by a piece of folded rubber tissue extending 
from the epididymis to the lower angle of the wound. The wound in 
the scrotum should now be sut- 
ured with silk or fine silkworm 
gut after suture of the tunica 
vaginalis with plain gut. The 
drain is usually removed on the 
second day and the skin sutures 
are removed on the seventh day. 
Relapse is said to be very rare. 

Acute Orchitis.— This condi- 
tion may arise as a complication 
of local infection, or it may occur 
as a complication of infectious 
parotitis. It is rarely associated 
with epididymitis. The reaction 
following trauma somewhat re- 
sembles an infectious process, 
but it usually subsides without 
suppuration. Occasionally the 
traumatic cases may develop 
into true infectious orchitis which 
may go on to abscess-forma- 
tion. In the orchitis of mumps, 

which sometimes occurs without evidences of parotitis, suppuration 
occurs in a small percentage of cases. An abscess of the testicle 
may be recognized by the persistence of the swelling, adhesions be- 
tween the testicle and the skin, and localized tenderness and fluctu- 
ation. 

Treatment.— In the early stages the treatment is the same as for acute 
epididymitis, namely, rest, support, and measures for the relief of pain. 
When abscess-formation occurs an incision should be made at the 
location of the fluctuation, or in the absence of fluctuation at the point 
of greatest tenderness. The wound is packed widely open and allowed 
to heal by granulation. In making the incision the epididymis and 
large veins on the inner side of the testicle should be avoided. Healing 
is generally complete in about three weeks. 




Fig. 364. — Mumps involving the left 
testicle, four days' duration. 



484 AFFECTIONS OF EXTERNAL GENITALS OF MALE 

Stricture of the Urethra.— A cicatricial constriction of the urethra 
sufficient to diminish free urination is known as a stricture. Pressure 
from without due to new growths or to inflammatory conditions may 
diminish the flow as do foreign bodies or tumors within the urethra. 
This latter condition is known as obstruction and is not a true stricture. 
Clinically it is sometimes quite difficult to distinguish whether stricture 
or obstruction is present. A wound may make it difficult or impossible 
to pass a sound or catheter, and yet there may be no impediment to 
the urinary flow. Stricture usually follows severe gonorrhea, but it 
may occur after any injury to the urethra, either inflammatory or 
traumatic. If untreated, the constriction slowly grows tighter and 
tighter until complete retention of urine results. Congenital narrowing 
of the urethra is not uncommon, but sufficient narrowing to constitute 
a true stricture is very rare except at the meatus. 

Treatment. —Two methods of treatment are available: (1) Dilata- 
tion by sounds; (2) operation by external or internal urethrotomy. 
The treatment by sounds is the only treatment which is practical in 
the ambulatory practice. The principle of treatment by sounds is the 
gradual stretching of the scar tissue at the point of stricture. Urethro- 
tomy consists of dividing the stricture with a sharp knife either from the 
inside of the urethra or through an external incision. While external 
urethrotomy can sometimes be done under local anesthesia, it is 
occasionally associated with considerable shock and is properly a 
hospital operation. In general, urethrotomy is only practised in the 
case of firm cicatricial strictures which do not yield to gradual dilata- 
tion. 

The patient is prepared for dilatation by washing the region of the 
meatus with weak antiseptic solutions and then passing a smooth 
sound of a size that will easily pass through the stricture into the 
bladder. This must be done with the same strict attention to asepsis 
as for a clean surgical operation. A second sound, of such a size as to 
fit snugly into the stricture, is then passed. After this a sound one 
size larger is passed if it can be done without much pain. The treat- 
ment is then discontinued for the day and the patient is told to return 
in two days, at which time two or three sounds are passed. It will be 
found in suitable cases that the urethra is steadily growing larger and 
that larger and larger sounds can be introduced on successive days. 

The treatment must be kept up until there is no progress or until 
a 30 or 32 F. sound can be passed. After this is accomplished the 
treatment should be given at monthly intervals for a year or more to 
prevent recurrence. In undertaking the cure of stricture by dilatation, 
it is well to warn the patient that successful results will require many 
months of treatment. In some cases a general anesthesia may be 
required, but ordinarily the above treatment although slightly painful 
is borne well. Local anesthesia of the urethra is usually considered 
dangerous and should not be used. Death following the instillation of a 
4 per cent solution of cocain has been reported. 



DISEASES OF THE MALE EXTERNAL GENITALIA 



485 



Urinary Fistula.— Frequently following old stricture with extravasa- 
tion of urine, a condition of chronic cellulitis, with or without abscess- 
formation, results.. Old cases show an area of induration which may 
be located on the penis or scrotum, extending in some cases onto the 
perineum or thighs. Through incision or the spontaneous rupture of 
localized abscesses, fistulse which tend to persist and become chronic, 
result. We have seen some cases with twelve or more openings, all 
discharging urine. Some cases of this type are tuberculous in character. 

Treatment. —The treatment is similar to the treatment of a chronic 
ischiorectal fistula. An external urethrotomy, with dissection of the 
fistulous tracts, will sometimes result in cure; but prognosis as a rule 
is poor, recurrences being common. 

Hydrocele.— A hydrocele is a collection of fluid in the tunica vagin- 
alis. It may occur secondary to disease of the testicle, but in most 
cases it occurs without evidences of inflam- 
mation or of other exciting cause. The fluid 
is clear, straw-colored, and slightly albumin- 
ous. The mass somewhat resembles a 
hernia but it can be distinguished by the 
fact that it is translucent and dull on per- 
cussion, whereas a hernia is opaque and is 
often tympanitic. The translucency test is 
made by rolling a sheet of heavy paper so 
as to form a tube about twelve inches long 
and one-half of an inch in diameter. The 
wall of the tube should be heavy enough to 
exclude light. One end of the tube is placed 
against the suspected hydrocele. If the 
examiner looks through this tube toward a 
bright light 1 a hydrocele will appear pink and 
translucent while a tumor or hernia will 
transmit light very slightly or not at all. 

There are practically no symptoms of 
hydrocele except the inconvenience caused 

by the presence of the tumor. Occasionally a patient may complain 
of slight pain. The swelling may increase in size until it reaches 
enormous proportions. Hydroceles as large as oranges are very 
common. Occasionally one is seen six or eight inches in diameter. 

Depending on anomalies of the tunica vaginalis there are several 
different types of hydrocele. Vaginal hydrocele is the ordinary type, 
the fluid being contained in the tunica vaginalis. In congenital hydro- 
cele, the funicular process between the peritoneum remains patent. 
In such cases if pressure is made on the sac the fluid runs back into the 
abdomen. In infantile hydrocele, the funicular process is closed at the 
internal ring but open into the tunica vaginalis, so that an elongated 
swelling occurs extending along the cord. A funicular hydrocele is 




Fig. 365. — Double hydro- 
cele with edema of the geni- 
tals, secondary to sarcoma of 
the prostate. 



1 An electric light held close to the opposite side of the mass. 



4§6 



AFFECTIONS OF EXTERNAL GENITALS OF MALE 



one which occurs in the funicular process and is open above but closed 
at the lower end. An encysted hydrocele of the cord is one occurring 
in the funicular process which is patent along the cord by obliterated 
above and below. It appears along the cord as an elongated tumor 
which cannot be reduced into the abdomen as a hernia and does not 
disappear on pressure as does a funicular hydrocele. 

Treatment.— In hydrocele of the funicular process, infantile and 
congenital hydrocele, support of the scrotum and the use of a truss to 
prevent hernia will often effect a spontaneous cure. Such cases occur 
ordinarily in children and require little or no treatment. 

In primary hydrocele occurring in adults conservative treatment 
will accomplish little or nothing towards a cure. Some form of opera- 
tion will be required in every case. The simplest form of operation is 
aspiration. After the skin is prepared for operation a few drops of 
novocain are injected into the skin on the anterior surface of the scro- 
tum. A small aspirating needle is then plunged into the sac, care 
being taken to avoid injury to the testicle which almost always lies 
posteriorly. After the fluid has been removed, the puncture is sealed 
with a little collodion; a fairly firm suspensory is applied; and the 
patient is allowed to go home. Recurrence after this form of treatment 
is the rule, but there is usually a period of several months before tapping 
is again required. 

Tapping with the injection of carbolic acid or other irritant has been 
extensively practised. It is not particularly advised because it is 
followed by an extensive reaction and is seldom curative. The opera- 
tion is performed as follows : The preparation of the operative field is 
carried out as above, but after the sac has been tapped and before the 
fluid has been allowed to escape an ordinary hypodermic containing 
from 15 to 30 minims of 95 per cent carbolic acid is introduced near 
the aspirating needle so that the point of the hypodermic needle may 
be made to touch the aspirating needle within the sac. The fluid is 
now allowed to escape and the residue is expressed by pressure on the 
scrotum. After making certain by contact with the aspirating needle 
that the point of the hypodermic is still in the sac, the carbolic acid is 
injected and both needles are quickly withdrawn. By manipulation 
of the scrotum, an attempt is made to smear the carbolic acid over the 
entire surface of the sac. A firm support is applied and the patient is 
told to rest for a few days. Immediately following the injection the 
testicle will swell to three or four times its normal size and then gradu- 
ally will decrease in size as the reaction subsides. 

A simple operation, and one often followed by success, is to make a 
small incision through the skin and the tunica vaginalis and through 
this incision to swab the entire sac with 95 per cent carbolic acid, 
washing out the excess with alcohol. The sac is packed with gauze 
and an antiseptic dressing is applied. After forty-eight hours the 
packing may be removed and the wound allowed to close. 

If the condition is of long standing, the thickened wall will not 



DISEASES OF THE MAKE EXTERNAL GENITALIA 



487 



collapse and excision of a portion of the sac should be performed. An 
incision about two inches long is made and the sac is identified and 
dissected away from the surrounding tissues. A large piece of the sac 
is excised, the edges are sutured to the skin, the sac is packed with 
iodoform gauze, and the wound is dressed. The packing is gradually 
decreased from day to day, and the wound allowed is to heal by 
granulation. Care must be exercised in this operation not to injure 
the testicle or the vas deferens. Jaboulay's operation consists of 
removing the testicle and the sac from the scrotum, incising the sac 
and turning it back over the testicle, which is replaced in the scrotum 
with the sac turned inside out. The wound is closed without drainage. 

Varicocele.— A varicocele is a 
varicose enlargement of the veins 
of the spermatic cord, and oc- 
curs almost invariably on the 
left side because the left sper- 
matic vein is longer, has no 
valves, and empties into the 





Fig. 366. — Right sided varicocele. 



Fig. 367. — Inguinal hernia, right; 
varicocele, left. 



left renal vein at a right angle. The right spermatic vein, on the other 
hand, has one or more valves and empties into the vena cava at an 
acute angle. Varicoceles have been ascribed to abdominal straining 
when coughing or constipated and to occupations requiring prolonged 
standing. Exceptional pressure from an abdominal tumor or inflam- 
matory exudate may act as a causative factor. 

The condition is manifest by an irregular swelling in the scrotum 
which may extend up the cord. On palpation the scrotum and 
enlarged veins somewhat resemble a bag of earthworms. The swelling 
diminishes on lying down and increases on standing. In advanced 
cases the left side of the scrotum is elongated, the testicle may be 
slightly atrophied, and the skin of the scrotum may contain varicose 
veins. 



488 AFFECTIONS OF EXTERNAL GENITALS OF MALE 

Symptoms.— The symptoms are variable. Some patients with a 
large varicocele show no subjective symptoms whatsoever, while others 
with varicosities much less marked complain of aching and dragging 
sensations, pains in the back, neuralgic pains in the testicle, and all 
manner of reflex disturbances. There may be mental depression and 
marked hypochondriasis. 

Treatment. —Ordinarily operation is not justifiable. If slight or 
moderate enlargement is present the patient should be told that the 
condition is not a serious one and that there is no danger of impotence 
or sterility. Cold baths may be advised and a suspensory bandage 
worn during the day. 

In very large varicoceles and those which cause the patient extreme 
discomfort or much mental anguish, it is best to operate. Young men 
are frequently found physically unfit for government positions because 
of a small varicocele which has never caused symptoms. In such cases 
it is necessary to operate. A few years ago a large percentage of 
varicocele operations performed in New York City were done in order 
to permit applicants to pass the examination for the Police Department. 

Either local or general anesthesia may be used for the operation. 
After preliminary preparation of the skin, incision is made over the 
external ring in the long direction of the cord. The fascia is carefully 
excised down to the cord and the vas deferens and surrounding arteries 
and veins are held aside. A portion of the large veins is now surrounded 
by two ligatures which are tied about one and a half inches apart. 
The veins between the ligatures are excised and the ligatures are tied 
together so that the stumps are approximated and the veins of the cord 
shortened. It is important that enough veins be ligated to diminish 
the number of engorged veins, but not sufficient to interfere with the 
nutrition of the testicle. Usually about two-thirds of the large veins 
can be tied without injury to the testicle. Bloodgood has drawn 
attention to the fact that if the genitocrural nerve is cut the relaxation 
of the cremaster muscle will tend to cause recurrence of the varicocele. 

The old operation of excision of the veins through a scrotal incision 
has been practically abandoned. If it is considered desirable to remove 
the veins in the scrotum, they should be drawn up through the incision 
over the external ring and excised. 

After the operation is completed the skin should be sutured without 
drainage and the patient kept in bed for several days. Following the 
operation there is usually considerable swelling of the testicle with 
pain radiating upward along the cord. The testicle should be kept 
elevated on an adhesive-plaster bridge so as to prevent congestion and 
excessive edema which tend to cause increased pain. A suspensory 
bandage should be worn for several weeks following operation. 

Tuberculosis.— Tuberculous ulcer may occur as a rare condition in 
the urethra or about the head of the penis. It is almost always second- 
ary to tuberculosis of the kidney or of the bladder. The treatment of 
ulcer of the deep urethra is practically identical with that employed 



DISEASES OF THE MALE EXTERNAL GENITALIA 489 

for tuberculous cystitis. When the ulcer is situated on the foreskin 
or glans it should be curetted and dressed with iodoform gauze. 

Tuberculosis of the testicle may occur primarily, but it is usually 
secondary to tuberculosis of the kidney, prostate, bladder, or seminal 
vesicles. The disease usually starts in the epididymis and is later 
transmitted to the testicle. The process is apt to extend up along the 
cord and to involve the vas deferens and the seminal vesicles. It 
usually begins in one testicle but it is liable to extend to the other after 
several weeks or months. The disease may begin gradually; it may 
follow an injury to the testicle; or it may become evident shortly after 
acute inflammation such as orchitis complicating mumps. In the 
beginning there is only a slight nodular swelling in the epididymis. 
Later the epididymis becomes swollen and the cord is felt as a nodular 
mass extending into the groin. Rectal examination may show involve- 
ment of the prostate and seminal vesicles. There may be a slight 
hydrocele of the tunica vaginalis. There is often only slight pain 
and rarely any disturbance of urination. In other cases the testicle 
becomes large and very painful and there may be evidences of mixed 
infection. In any event, the nodules tend to run together and break 
down. The disease is usually chronic but may end in recovery after a 
period of several years. In cases of long duration the disease may 
spread to the perineum and thighs, resulting in the formation of multiple 
tuberculous fistulas, which may or may not discharge urine. 

Treatment.— In any case general treatment for tuberculosis should 
be instituted as soon as possible. It is claimed that the climate of 
southern California is especially beneficial in this type of tuberculosis. 
Exposure to the sun as practised in southern California, Arizona, and 
New Mexico cures a large percentage of such cases. 

Da Costa advises the use of Bier's method of passive congestion 
before attempting operation. The testicle is lifted forward and a piece 
of rubber drainage-tube is passed twice around the neck of the scrotum 
and held with a clamp or string. The patient should be recumbent 
during the treatment which is applied for from two to six hours daily. 
During the intervals the patient may be allowed to be up and about 
with the testicle supported by a suspensory bandage. This may be 
combined with heliotherapy, as mentioned above. Recently we have 
been using the quartz mercury vapor light in cases of this type, appar- 
ently with some success. We feel that it is to be used only when sun- 
light is not available and not as a substitute for it. 

The advisability of operation should be considered if other methods 
of treatment fail. It is almost impossible to remove all the tuberculous 
disease, but is it possible that the removal of the epididymis and of 
the testicle may hasten the healing of the other tuberculous foci. In 
an early case where the condition is limited to one epididymis, operation 
with removal of the entire testicle and cord may result in an apparent 
cure; but in old cases where both testicles are involved it is perhaps 
better to remove only the diseased portions of the glands. In the cases 



400 



AFFECTIONS OF EXTERNAL GENITALS OF MALE 




Fig. 368.— Syphilis of the testicle, 
three months' duration. 



showing sinuses the injection of iodoform emulsion and the use of 
tuberculin may be followed by excellent results. 

Syphilis.— Syphilis commonly occurs as a primary chancre of the 
penis, which is the ordinary location for the initial lesion. During the 

secondary stage mucous patches occur 
about the glans penis and on the under 
surface of the foreskin. These affections 
are fully described in works on genito- 
urinary surgery. 

Syphilis of the Testes.— This is a very 
common tertiary lesion and is said to 
occur in over one-third of all syphilitics. 
It is of interest to the general surgeon 
because it must be differentiated from 
tuberculosis and sarcoma of the testicle. 
The testicle is enlarged and heavier 
than normal but there is little or no 
pain. The sensation of nausea which 
is caused by squeezing a normal testicle 
is practically entirely absent on squeez- 
ing the syphilitic testicle. The con- 
dition may disappear either with or 
without treatment or the gumma may 
break down and discharge externally. The treatment consists of sup- 
port of the testicle and antisyphilitic measures for the control of the 
disease. 

DEFORMITIES OF EXTERNAL GENITALS OF MALES. 

Deformities of the penis, with the exception of phimosis, and hypo- 
spadias, are much less common than deformities of the uterus and 
vagina. The so-called hermaphrodites are often males in whom the 
penis is congenitally absent and the scrotum poorly developed and 
possibly bifid. Partial or complete absence of the urethra or double 
urethra occurs so seldom as to be classed as a surgical curiosity. 
Developmental defects of the testicle on the other hand are very com- 
mon. The testicle may be retained in the abdominal cavity or it 
may be arrested during its descent through the inguinal canal. Less 
commonly the testicle may be displaced out of its normal track and 
rest either in the perineum or elsewhere in the subcutaneous tissue 
adjacent to the penis or scrotum. 

Congenital Stricture of the Urethra.— Congenital stricture or even 
atresia of the urethra usually occurs at the meatus but may occur else- 
where. If the obstruction is complete it will be noticed shortly after 
birth, but if incomplete it often is not noticed until adult life. Unless 
the stricture is small enough to interfere seriously with urination it 
gives no symptoms and does not require treatment; but if the patient 
acquires a urethritis, it becomes necessary to divide the stricture to 



DEFORMITIES OF EXTERNAL GENITALS OF MALES 491 

prevent the accumulation of pus behind it which tends to prolong the 
inflammation. 

The presence of a stricture at the meatus may be demonstrated by 
the use of a probe passed into the fossa navicularis. If the rounded 
end of the probe is drawn along the floor it meets a thin membranous 
obstruction just before it is withdrawn. This obstruction is always 
on the floor and is usually only a thin membrane. When congenital 
stricture occurs in other parts of the urethra, which is very rare, the 
stricture consists merely of the narrowing of the lumen. 

Treatment.— In atresia of the meatus occurring in the new born, the 
obstruction is usually only a thin membrane which may be easily 
punctured with the point of a knife. The urethra is kept open by the 
use of a small probe until healing is complete. Where the atresia 




Fig. 369. — Large right scrotal hernia, drawing skin down and causing complete dis- 
appearance of penis. The mouth of the opening had so thickened from irritation of 
urine that it could not be retracted. Patient aged seventy-two years; duration about 
nine years. 



occurs in another part of the urethra, urination is apt to occur through 
the urachus which remains patent. If there is retention of urine, 
operation for deep atresia must be performed at once. External ure- 
throtomy or puncture of the bladder with a small trocar may be 
required. 

Meatotomy.— Meatotomy is required in adults in order to prevent 
prolongation of the period of infection in cases of urethritis and in 
order to permit the introduction of sounds. The penis is washed with 
soap and water and the region of the glans is wrapped for a few minutes 
in gauze wet with 50 per cent alcohol. A few drops of novocain solu- 
tion are injected at the lower margin of the meatus and with a blunt- 
pointed bistoury the membranous obstruction is cut from within 
outward. The incision is always made on the floor of the urethra. 
The free passage of a probe or bougie shows that all obstructions have 



492 



AFFECTIONS OF EXTERNAL GENITALS OF MALE 



been removed. Hemorrhage may be controlled by direct pressure and 
the wound smeared with sterile vaseline and packed with a small piece 
of gauze which is removed by the patient during the next act of mic- 
turition. To prevent infection a small dressing may be conveniently 
applied over the end of the penis. The patient should be instructed 
to bathe the wound in hot boric acid solution twice daily. A sound 
should be passed through the meatus every two days for about two 
weeks to prevent adhesions. 

In the deep congenital strictures occasionally found in adults the 
stricture must be divided by internal or external urethrotomy in the 
same manner as in cicatricial stricture following urethritis. 

Phimosis.— Phimosis is a contraction of the opening of the prepuce 
so great that the glans penis cannot be uncovered by retraction of the 
prepuce. In the congenital deformity the opening may be ^arge 
enough to permit a free flow or it may be very small and seriously 




Fig. 370. — Phimosis. Age sixteen years. (Ashhurst.) 



interfere with urination. The acquired variety is generally due to 
inflammatory changes in the prepuce which cause contraction of the 
loose preputial skin. Both types are apt to be complicated by adhe- 
sions between the prepuce and the glans penis and by a certain amount 
of balanitis. 

As a rule there are no symptoms associated with phimosis until the 
secretions retained beneath the foreskin cause irritation. This irrita- 
tion is an active cause of masturbation in children. In adults the 
continual irritation may lead to the formation of ulcers or preputial 
calculi. It is claimed that phimosis increases the susceptibility to 
venereal disease. 

Treatment.— In the new born when the condition interferes with 
urination a small incision should be made at the opening and a small 
grooved director should be introduced beneath the prepuce. With 
the director as a guide a dorsal slit is made so that the glans may be 



DEFORMITIES OF EXTERNAL GENITALS OF MALES 493 

easily uncovered. With a small probe the adhesions between the fore- 
skin and the glans may be easily broken. One or two stitches may be 
introduced between the skin and mucous membrane at the edges of 
the incision. The penis is smeared with sterile vaseline and a dry 
dressing is applied and held in place with the diaper. Each time the 
napkin is changed the penis should be dressed with a compress of sterile 
gauze. 

In older children adhesions often prevent the retraction of the pre- 
puce, and cause an apparent phimosis. The adhesions can be broken 
by the use of a probe introduced between the prepuce and the glans. 
After retraction is complete the glans is well smeared with sterile 
vaseline and the mother is instructed to retract the foreskin daily for a 
week or more to prevent recurrence. In adults phimosis is an indica- 
tion for circumcision. 

Circumcision is advised for children in whom retraction is impossible 
and for adults in whom the prepuce is long and tight, even though 
actual phimosis is not present. In children the long foreskin has been 
the apparent cause in certain cases of abnormal nervous development. 
Its removal has tended to diminish masturbation and to have a favor- 
able influence upon certain borderline cases of nervous disease such as 
epilepsy, convulsions, chorea, tic, etc. In adults circumcision dimin- 
ishes masturbation and decreases the desire for excessive intercourse. 
It also tends to delay the sexual climax during intercourse, making him, 
in the words of a patient, "sexually stronger." 

The operation may be performed under local anesthesia by the 
injection of novocain solution about the base of the penis. 1 This 
usually anesthetizes the entire penis but in some cases additional 
injections are required beneath the mucous membrane about the 
corona. A constricting band should be placed about the base of the 
penis to prevent hemorrhage and to increase the action of the novocain. 
In children up to ten or twelve years of age it is better to use general 
anesthesia, as the fear of the operation makes them squirm and move 
about so that a careful operation is impossible. 

The penis and scrotum are prepared for operation by thorough 
washing with soap and water and by rinsing with sterile water, followed 
by the application of gauze wet with 50 per cent alcohol (the ordinary 
preparation with iodine is almost certain to result in blistering). 

Keyes advises the use of circumcision forceps. These are long, 
narrow, straight-bladed forceps and are applied as follows: The 
prepuce is caught at the upper and lower angles of the opening by 
artery-clamps or mouse-tooth forceps and is drawn forward as far as 
possible. The circumcision forceps are applied at an angle of about 
60 degrees to the long axis of the penis, the point of the forceps at the 
lower artery-clamp and the blades of the forceps roughly parallel to the 
upper surface of the glans. Care must be taken not to include any 

1 See chapter on Local Anesthesia. 



494 



AFFECTIONS OF EXTERNAL GENITALS OF MALE 



of the glans in the forceps. The portion distal to the forceps is cut 
away, the forceps are removed, and the skin is slipped back, exposing 
the mucous membrane more or less adherent to the glans. Adhesions 
are broken up and a dorsal slit is made in the mucous membrane to 
within about one-quarter of an inch of the corona. The mucous 
membrane is trimmed laterally obliquely toward the frenum so that a 
collar of mucous membrane about one-quarter of an inch in width is 
left about the corona. In trimming the lower part care must be 
taken not to injure the frenum. All the bleeding points are ligated 
and the skin and mucous membrane are sutured with catgut or silk. 
The stitches should be placed close together to prevent hemorrhage. 
If the alternate sutures are left long a strip of gauze may be tied about 
the penis covering the incision. The head of the penis and gauze 
are then well greased with sterile vaseline and the penis is dressed with 
sterile gauze held in place by a loose suspensory bandage. The patient 
need not remain in bed, but it is better to rest during the first twenty- 
four hours. After each urination the patient removes the gauze and 
replaces it with another sterile compress. Unless infection occurs, 
the sutures and the circular strip are left in place about a week. 

The use of circumcision forceps is condemned by some surgeons as 
apt to lead to irregularities and deformities of the foreskin, and because 
the too rigid application of the clamp may cause injury to the prepuce. 

The operation may be performed by the lateral-flap method without 
the use of clamps. A dorsal incision is made along the mid-line to 
within about a quarter of an inch of the corona with a pair of blunt- 
pointed scissors using a grooved director as a guide, or the upper 
margin of the preputial opening may be held by two sharp-pointed 
artery clamps. A similar incision is made in the mid-line below to 
within half an inch of the frenum. 1 Two stitches are taken at the 
angles of these incisions, the ends being left long to act as retractors. 
With a pair of sharp scissors the lateral flaps are trimmed away so that 
about half an inch of the mucous membrane is left. Care must be 
taken not to cut away too much skin or mucous membrane. The 
tendency is to make traction upon the skin when the skin is divided. 
This must be studiously avoided, for the resulting retraction of the 
skin may be so great as to make suture impossible. It is always better 
to leave too much skin than too little. The lateral flaps should be cut 
smoothly so that irregular tabs of skin or mucous membrane will be 
avoided. Using the stitch at the frenum and the dorsal stitch for 
retractors, two lateral stitches are placed, one in the middle of each 
side. If this is done the edge remains even throughout, and the 
remaining stitches may be placed without fear that the foreskin will be 
drawn unevenly. The after-treatment is the same as outlined above. 

Secondary hemorrhage may occur after circumcision. If all vessels 
are carefully ligated it should seldom be severe enough to require 



1 The common mistake is to make this incision too large, thus injuring the frenum. 



DEFORMITIES OF EXTERNAL GENITALS OF MALES 495 

treatment. Hemorrhage may occur externally or subcutaneously 
and may be severe enough to endanger life. It may be controlled when 
slight by direct pressure or possibly by the use of cold. When severe, 
the wound should be opened and the vessel ligated. If a subcutaneous 
hematoma forms it may usually be expressed through an opening made 
with a probe in the line of suture. 

Infection, if it occurs, should be treated by the removal of one or 
more stitches and the application of wet dressings kept constantly wet 
with hot boric acid solution. Owing to the excellent blood supply 
of the penis, serious infection following circumcision is very rare. 

Rupture of the line of sutures as a result of erection or the cutting 
through of sutures because of too great tension is not uncommon. 
Such cases usually heal in three or four weeks by the growth of epithe- 
lium over the denuded surface. 

Hypospadias.— Hypospadias is a deformity due to the arrested 
development of the urethra. The urine is passed through an opening 
on the inferior surface of the urethra or perineum. There is often 
a dimple at the location of the normal external meatus but no distinct 
opening. In the simplest form, which is quite common, the urethra 
opens only a short distance behind the normal opening on a level with 
the corona or just posterior to it. The opening is usually small, not 
more than half the size of the normal meatus. The urethra, except 
for its terminal portion, is often found normal in size, although other 
congenital malformations sometimes occur. In the more pronounced 
form the opening may be near the base of the penis or even on the 
perineum, and the penis may show a groove along the inferior surface 
corresponding to the location of the undeveloped urethra. 

When the opening is near the end of the penis, the condition is 
unimportant. Many patients with a slight degree of hypospadias 
are unaware of the fact. There may be inconvenience due to a slight 
dribbling at the end of urination. It is commonly believed that 
hypospadias predisposes to urethral infection. It is certain that its 
presence makes the treatment of a gonorrheal urethritis more difficult 
and tends to prolong the period of recovery. 

Hypospadias with the opening nearer the base of the penis or on the 
perineum, while much less common, may cause great inconvenience. 
The patient is obliged to urinate in a squatting position to keep from 
wetting himself and erection may be so imperfect as to prevent coitus. 
Impotence may be caused by the inability to throw the semen into the 
vagina. 

Treatment.— Balanitic hypospadias ordinarily requires no treatment 
unless the opening is so small that it interferes with urination. When 
it is desired to introduce sounds into the urethra or instruments into 
the bladder, it is almost always necessary to enlarge the opening. 
The operation is performed by making a small longitudinal slit in the 
median line on the under surface of the penis, somewhat similar to 
meatotomy. 



496 



AFFECTIONS OF EXTERNAL GENITALS OF MALE 



For the more serious deformities, a plastic operation with the 
formation of a new urethra is always required and should be performed 
before puberty. 




Fig. 371. — Infantilism in a boy, aged seventeen years. Left undescended testicle with 
small inguinal hernia. Hypospadias with rudimentary penis. 

Epispadias.— Fortunately this condition is very rare. It consists of 
a fissure in the superior wall of the urethra and is frequently associated 
with exstrophy of the bladder. Owing to the fact that the urethral 
sphincter is often involved there is almost always incontinence of urine. 
There are symptoms referable to incomplete erection and ineffectual 
emissions as in hypospadias. 

Treatment.— The treatment consists of the use of some form of urinal 
to be worn constantly in cases showing incontinence of urine, and 
careful care of the skin to prevent irritation. Operation has not as a 
rule been followed by satisfactory results. If there is no incontinence, 
it is perhaps best to leave the condition alone; but the severe cases 



DEFORMITIES OF EXTERNAL GENITALS OF MALES 497 

demand some form of operation even if there is only slight promise 
of relief. The various surgical procedures ordinarily recommended 
usually require several operations and are often followed by failure. 
They are described in special works on genito-urinary surgery. 




Fig. 372. — Undescended testicles in a man, aged forty-one years. Left testicle can be 
seen and felt just below ring. No spermatozoa in semen. 

Undescended Testicle.— This is the most common variation in the 
development of the testicle. The testicle, if located in the inguinal 
canal or over the pubes, is more liable to injury than when it is in its 
normal position. The condition is always associated with a protrusion 




Fig. 373. — Undescended testicles in a man, aged twenty-four years, father of two 
children. Spermatocele in right groin. 



of the peritoneum which may develop into a true hernia. This is 
because the testicle keeps the canal patent. The testicle is apt to be 
small, rarely functionates, and is said to undergo frequently malignant 
changes. 
32 



498 



AFFECTIONS OF EXTERNAL GENITALS OF MALE 



It is claimed that during infancy a pad or truss may be used to aid 
the descent of the testicle. Results are usually unsatisfactory. 
Armstrong claims to have seen the descent of a testicle after the 
administration of thyroid extract for a period of three months. 

Operation for the repair of the accompanying hernia should be 
undertaken, preferably between the eighth and twelfth years. At 
the time of operation it is frequently possible to bring the gland down 
into the scrotum. 

TUMORS OF THE PENIS. 

Cysts.— Implantation and sebaceous cysts occur on the skin of the 
penis, generally on the prepuce. They are readily enucleated under 
local anesthesia. 




Fig. 374. — Beginning fungating carcinoma of the penis. (Hertzler.) 

Papillomata. — These are very common, usually occurring on the 
glans penis, and are frequently called venereal warts, although there is 
no necessary connection between them and venereal disease. They are 
highly vascular and nearly always multiple. The commonly accepted 
cause of papillomata is irritation due to the retention of inflammatory 
discharges beneath the foreskin, or simple uncleanliness. They may 
occur on the prepuce or even on the scrotum. The surface is rough 
and irregular, in contradistinction to syphilitic condylomata, which 
are uniformly flat. In patients past mid-life it is very difficult to dif- 



TUMORS OF THE PENIS 



499 



ferentiate a papilloma from a beginning epithelioma. The diagnosis 
in many cases can be made only on the microscopic findings. 

Treatment.— The penis should be washed daily with soap and water, 
carefully dried, and the glans dusted with powdered calomel. In 
many cases this will cause the vegetations to dry up and disappear. 
In persistent cases circumcision may be required. Pedunculated 
growths may be snipped off with curved scissors and the base touched 
with pure carbolic acid. Lactic acid in 1 per cent solutions may be 
applied daily in cases where there are extensive growths. When the 
warts are external they should be snipped away with curve scissors, 
care being taken not to produce a large scar which may contract and 
interfere with coitus. 

Fibromata.— An area of circumscribed fibrosis sometimes occurs in 
the corpora cavernosa. It appears as a hard, flattened mass with 
fairly sharp margins and is thought by some to be an inflammatory 
affection, possibly secondary to gout. It may increase in size so as to 
interfere seriously with intercourse or it may disappear spontaneously. 
It never ulcerates but may, very rarely, undergo calcification or ossifica- 
tion. 

Treatment.— The treatment for this condition has been uniformly 
unsatisfactory. The internal administration of the iodides or mercury 
has been advised, but it has met with little success. Remedies for 
rheumatism or gout have been tried and in some cases their use has 
been followed by favorable results. Excision only replaces the fibrosis 
by scar-tissue and is not advised. Recently beneficial results have 
been reported after the use of radium and the roentgen ray. 




Fig. 375. — Epithelioma of penis. Cauliflower (fungating) mass involving glans and 
prepuce. One years' duration. Edema of dependent portion of prepuce. Bilateral 
enlargement of inguinal lymph glands. (Corbett.) 



Epithelioma of the Penis.— This condition is not uncommon and 
occurs usually after the fortieth year. It begins frequently as a wart- 
like growth situated on the glans penis or on the inner surface of the 
prepuce. This wart does not yield to ordinary treatment and recurs 
if excised, Later the growth becomes tabulated and the surface 



500 AFFECTIONS OF EXTERNAL GENITALS OF MALE 

ulcerates. The inguinal glands are involved early. Occasionally 
the disease begins as a small ulcer similar to the slow-growing epithe- 
liomata which occur on the face. It is claimed that the disease 
is more frequent in men with phimosis because of the retention of irri- 
tating secretions. In some cases the epithelioma starts from a spot of 
leukoplakia or from a preexisting benign growth. 

The disease must be differentiated from papilloma, tuberculous 
ulcer, chancre, and chancroid. 

Treatment.— It is of first importance in every ulcer of the penis, and 
especially in those occurring at the cancer age which do not yield readily 
to treatment, to determine whether or not the disease is cancerous. 
This may be done by cutting a wedge-shaped piece from the margin 
of the ulcer for microscopic examination. 1 In the early stage it may be 
possible to remove the growth by excision, but this is apt to be followed 
by recurrence. In the late stages amputation of the penis and excision 
of the inguinal glands are required. During the last few years we have 
seen several cases treated with radium at the General Memorial 
Hospital, New York City. The results have apparently been at least 
as good as those following surgical removal. 

Sarcoma. — Sarcoma of the penis is very rare. It begins as a fibroid 
tumor in the corpus cavernosum. Pressure may cause priapism and 
retention of urine. The treatment is limited to amputation of the 
penis but recurrence is almost certain to occur. 

TUMORS OF THE SCROTUM AND TESTICLE. 

Cysts.— Cysts of the scrotum are not uncommon. Small sebaceous 
cysts approximately the size of a split pea are frequently seen. As a 
rule they do not increase in size and require no treatment. Occasion- 
ally a sebaceous cyst increases rapidly in size and may become in- 
flamed. Small blood-cysts two or three millimeters in diameter 
sometimes occur abundantly just beneath the superficial layer of the 
epidermis. They give rise to no symptoms but may cause annoyance 
to the patient because of their appearance. They may be cured by 
pricking them with the point of a knife and touching the inner surface 
with pure phenol. 

Epithelioma of the Scrotum.— Epithelioma of the scrotum is fairly 
common in England where it is called " chimney-sweeps' cancer" 
because it is thought to be due to the irritating action of soot upon the 
scrotal epithelium. It is probable that soot or any form of dirt con- 
stantly rubbed into the epithelium leads to irritation and ulceration 
and that this in turn undergoes cancerous change. The disease usually 
begins as a small warty growth which soon ulcerates and extends 
rapidly. 

1 There is strong evidence that incision for diagnostic purposes tends to spread the 
growth to the inguinal glands. In making a diagnostic incision, this danger should 
be borne in mind. Preliminary exposure to radium or roentgen rays would, theoretically, 
diminish the danger, 



TUMORS OF THE SCOTUM AND TESTICLE 



501 



Treatment.— The treatment consists of early excision of the growth. 
If the case has been allowed to progress, a radical operation with 
removal of the testicle and inguinal glands is required. Recurrences 
are common. 

Teratoma of the Testicle.— This is a mixed-cell tumor of the testicle 
containing sarcomatous, adenomatous, and sometimes cystic areas. 
Its clinical characteristics are those of a rapidly growing sarcoma. 

It may begin as a benign tumor and suddenly become malignant, 
or it may be malignant from the start. While benign tumors of the 
testicle can and do occur, they are so rare that every testicular tumor 
should be considered malignant. The surface of the tumor may be 
elastic or uneven, but the oval shape of the testicle is as a rule pre- 
served. The fact that the tumor shows cystic areas causes it to be 
mistaken for hydrocele. If the test for translucency is made, the 
difference is evident. Syphilis of the testicle is very similar to the early 
stage of teratoma. If the swelling does not decrease under anti- 
syphilitic treatment it is almost certainly malignant. As the disease 




Fig. 376. — Rapidly growing sarcoma of the testicle. Removed with cord, inguinal 
nodes and fat. Postoperative roentgen ray. No recurrenee after five months. 

progresses the iliac and deep lumbar glands become involved and may 
be felt through the abdominal wall. The inguinal glands are affected 
only when the scrotum is involved because the lymphatics from the 
testicle empty directly into the iliac and lumbar glands. Early radical 
operation is the only method of treatment worthy of consideration. 
Recurrence is the rule. Not only in teratoma but in all other malignant 
tumors of the external genitals, the results of surgery have, as a rule, 
been very poor. During the last five years a number of these cases 
have been treated with radium. While the results have not been 
uniformly favorable, they have been at least as successful as surgery, 
and give promise, with the gradual improvement of the technic of 
application, of much better final results than those previously secured 
by surgical methods alone. 

Cysts of the Epididymis.— Cystic enlargement of the epididymis is 
relatively common. The cysts begin ordinarily as small, rounded or 
oval, tense cystic tumors in the upper part of the epididymis and 
slowly increase in size. Two or more cysts may occur in the same 



502 AFFECTIONS OF EXTERNAL GENITALS OF MALE 

testicle, later fusing to form a single cyst. They tend to increase 
indefinitely and may rupture into the tunica vaginalis simulating 
hydrocele. When aspirated a thin milky fluid is obtained which 
contains spermatozoa. They are generally considered to be retention 
cysts caused by inflammatory changes. 

Smaller cysts occurring in men past middle age are usually due to 
cystic enlargement of the tubules due to senile changes. 

Treatment.— The treatment consists of the operative removal of the 
cyst before it become large enough to make the procedure difficult. 
Tapping may be performed as a palliative measure, but it is to be 
regarded as only temporary. For the smaller cysts occurring in older 
men no treatment is required. 



CHAPTER XIX. 
GYNECOLOGICAL MINOR SURGERY. 

WOUNDS OF THE FEMALE GENITALIA. 

Wounds of the female genitalia may be operative or accidental. 
Criminal assault and too violent coitus result, occasionally, in serious 
damage to the vulva and vagina. Owing to the high degree of vascu- 
larity of the tissues, wounds are likely to be associated with profuse 
hemorrhage. In contusion, for the same reason, ecchymosis is likely 
to be extensive. The wound should be carefully cleansed and sutured 
with fine silk or silkworm gut. Even with hemorrhage it is usually 
inadvisable to pack the wound, because, owing to the proximity of the 
rectum, infection is almost certain to be introduced. If care is exer- 
cised, the bleeding points may be caught and ligated, and capillary 
hemorrhage controlled by superficial sutures. Traumatic laceration 
of the perineum may occur with comparatively slight injuries. 




Fig. 377. — Complete prolapse of the rectum and uterus. 

HEMATOMA OF THE FEMALE GENITALIA. 

Hematoma of the vulva may result from contusion or may occur as 
an accident of parturition. Small hematomata are usually absorbed; 
but when the tumor is as large as an egg the chances are that it will 
require tapping or incision. The usual history is that after an injury 
to the vulva, the patient notices a swelling which increases rapidly in 
size. Under treatment this may gradually disappear, or, more fre- 



504 GYNECOLOGICAL MINOR SURGERY 

quently, it decreases in size for a few days and then becomes infected 
with an increase in local symptoms. 

Treatment. —The treatment during the early stage consists of the 
application of cold compresses or an ice-cap and rest in bed to avoid 
irritation. 1 When signs of inflammation occur, an incision should be 
made and the contents expressed. The cavity should be kept well 
packed with antiseptic gauze which should be changed daily. Compli- 
cations are very rare. 

LACERATION OF THE PERINEUM. 

Traumatic laceration of the perineum usually results from kicks or 
falls. While a lacerated perineum is a common and well-recognized 
complication of parturition, it is often overlooked when it occurs as a 
result of traumatism. For this reason the physician should insist 
upon a complete and thorough examination of the parts after any 
injury of the perineum. Serious lesions have been overlooked because 
of the hesitation of the patient to permit examination and the failure 
of the physician to insist upon it. The tear is usually in the median 
line and may extend into the rectum. Lateral tears are less common. 
As a general rule tears of the perineum are usually bilateral when they 
occur following parturition, and single when due to external trauma. 
It is important that the examination be complete so that the full 
extent of the tear can be determined. If the rectum is torn through, 
the mucous membrane should be identified and the torn ends of the 
levator ani located. 

Treatment.— In the smaller tears the only requirement is suture of 
the mucous membrane and skin after preliminary cleansing of the 
wound with peroxide of hydrogen or other antiseptic solution. Fine 
chromic sutures serve admirably for the suture of the vaginal mucous 
membrane. They should be placed deeply in the tissues so as to 
obliterate any cavity which may form. Care should be taken during 
the placing of the deep sutures not to pass the needle into the rectum 
which lies close to the vagina in the midline. The skin is sutured with 
silk or silkworm gut. 

In the deeper tears involving the levator ani muscle, the ends of the 
torn muscle must be identified on each side of the wound and brought 
together with a buried chromic suture. Otherwise, the wound is closed 
as described above. 

When the tear passes into the rectum, the mucous membrane of the 
rectum is first sutured with black silk sutures, so tied that the knots 
will be inside the rectum. The wound is then washed out thoroughly 
with peroxide of hydrogen and then rinsed with a large amount of 
sterile saline. The edges of the torn levator ani are then sutured 

1 We have recently seen a hematoma of the vulva which increased in size so rapidly 
and was so painful that immediate incisitfn and ligation of the bleeding point was 
required. 



VARICOSE VEINS OF THE VULVA 505 

together and the wound closed as already described. After this 
operation the patient should be given moderate doses of morphine 
so that the bowels do not move until the fourth day. When the bowels 
finally show a tendency to move, six ounces of sweet oil should be 
injected into the rectum and allowed to remain several hours. Just 
before the bowels move, a soap-suds enema should be given. 

In all cases during convalescence the external genitals should be 
washed with sterile saline or boric acid solution after urination. In 
the severer types the patient may be unable to urinate voluntarily and 
consequently catheterization is necessary. However, if the patient is 
able to void, catheterization should not be insisted upon. 

The milder cases may be allowed up after a few days ; but the severer 
cases, especially those in which the wound passes into the rectum, 
should be confined to bed for fifteen days or longer or until the wound 
has completely healed. Coitus should be forbidden for eight weeks 
or longer. The silkworm gut sutures in the skin should be removed 
after about ten days. The chromic sutures in the vagina are absorbed, 
while the silk sutures in the mucous membrane of the rectum usually 
slough out in about a week. 

Suppuration about the line of sutures is not uncommon, but it seldom 
amounts to more than a superficial infection about the stitch punctures 
and the edges of the wound. When it occurs it should be bathed 
frequently with boric acid solution (2 to 4 per cent) . 

Without treatment wounds of the perineum heal by granulation; 
but if the muscles are severely torn, the patient suffers from a lack of 
support and operative repair becomes necessary. Descriptions of 
secondary operations for the repair of the perineum are found in works 
on gynecology. 

VARICOSE VEINS OF THE VULVA. 

Varicose veins frequently occur in the vulva. They result from 
pressure on the veins in the abdomen and are most frequently seen 
during pregnancy as a consequence of increased intra-abdominal 
pressure. In the absence of pregnancy, a careful pelvic examination 
should be made to exclude pelvic tumor. 

The varicosities may be very small or they may be the size of a walnut 
or larger. Rupture may lead to severe or fatal hemorrhage. Throm- 
bosis may occur, and is likely to be associated with edema and indura- 
tion of the surrounding tissues. 

Treatment.— Hemorrhage can be controlled by pressure on the 
enlarged veins against the pubic portion of the pelvis. If it persists, 
the vein' should be exposed and ligated. In view of the fact that fatal 
hemorrhage has been reported, patients should be instructed how to 
apply firm, direct pressure against the bleeding point in case of rupture. 
The general tendency is simply to apply cotton and napkins to absorb 
the blood. When the veins become thrombosed and tender, the patient 
should be put to bed and an ice-cap should be applied to the painful 



506 



GYNECOLOGICAL MINOR SURGERY 



area. When the pain has diminished, the disappearance of the indura- 
tion can be hastened by the application of ichthyol ointment (25 per 
cent). After the cause ceases to act, that is, when the pregnancy is 
completed or the tumor removed, the veins give little or no inconven- 
ience. In the rare case where they do cause annoyance they may be 
excised. 

HYPERTROPHY OF THE EXTERNAL GENITALIA. 

The vulva may become enlarged as a whole, due to the occlusion of 
lymph channels with consequent accumulation of lymph in the lymph 
spaces and the enlargement of the part. This condition, which is 
common in the trophies and is known as elephantiasis, is occasionally 
seen in a less marked degree as a result of operative or inflammatory 
changes in the neighborhood of the vulva. The labia minora and the 




Fig. 378. — So-called hermaphrodite. Clitoris, when erect, five inches long; labia resem- 
bled cleft scrotum; vagina and uterus normal; menstruation normal. 

clitoris frequently show a slight or moderate degree of hypertrophy 
without apparent cause. Local irritation, such as would occur in 
masturbation or excessive coitus, has been held responsible for hyper- 
trophy of the clitoris, but the cause has not been definitely ascertained. 
The clitoris sometimes without apparent cause becomes enlarged to the 
size of the penis of a boy at puberty. Owing to irritation from clothing 
or from other causes, the enlarge parts may become inflamed or ulcer- 
ated. 

Treatment. — The only treatment for enlargement of the clitoris is 
excision. Unless the enlargement is sufficient to cause annoyance or 
sexual perversions, the operation should not be attempted. Complete 
amputation should be performed by making an incision around the 
organ and enlarging it above by a median incision. The clitoris is 
separated from its attachment beneath the pubis, and the wound is 
closed by deep and superficial sutures. Partial amputation is per- 



MALFORMATION OF THE VAGINA AND HYMEN 507 

formed in a similar manner, only part of the clitoris being removed. 
This operation should be performed with the utmost care, for it may be 
followed by infective phlebitis of the pelvic veins. Healing is usually 
complete in from six to ten days, but coitus should be forbidden for at 
least four weeks. 



ADHESIONS BETWEEN THE LABIA AND THE CLITORIS. 

This condition may follow vulvitis or it may occur without apparent 
cause. Usually the labia minora are adherent over the clitoris so as to 
hide this organ completely. When they are separated a collection of 
smegma is ordinarily found about the clitoris. In children the irrita- 
tion caused by this secretion is likely to lead to masturbation and bed- 
wetting. 

Treatment.— The adherent surfaces of the labia can usually be 
separated by steady pressure made with the thumbs on the opposite 
sides of the vulva. A blunt-pointed probe may be used to complete the 
separation of the clitoris. After the separation is complete the labia 
will be found bleeding at a number of points where the adhesions have 
been torn loose. These bleeding surfaces should be bathed with a weak 
antiseptic solution and sponged dry. The surfaces can be kept from 
reuniting by the use of a bland powder such as talcum or by the 
application of a mild antiseptic ointment such as boric acid ointment. 
In a few cases because of the density of the adhesions it has been found 
necessary to divide the tissues with a sharp knife. 

MALFORMATION OF THE VAGINA AND HYMEN. 

Numerous anomalies of the hymen and vagina may occur, including 
absence of the vagina, double or multiple orifices of the hymen, double 
vagina, and imperforate hymen. 

Atresia and imperforate hymen are rarely discovered before puberty. 
They result in an accumulation of menstrual blood above the obstruc- 
tion which is termed retentio mensium. The hymen alone may be 
obstructed or there may be atresia of a part or of all of the vagina. 
If the obstruction is at the lower part, the vagina becomes distended 
with blood (hematocolpos) and finally the uterus becomes thinned out 
and distended in the same manner (hematometra), and even the tubes 
may be involved (hematosalpinx) . 

If untreated the hematoma may become infected and rupture either 
internally or externally. The prognosis is grave in untreated cases. 
The diagnosis is based on amenorrhea associated with pain, the presence 
of a fluctuating tumor and inability to introduce the finger into the 
vagina. With each menstrual period the pain becomes more intense. 
If the hymen alone is involved, there will be a marked bulging at the 
vulva. Rectal examination will give considerable information as to 
the extent of the atresia. In some cases a dense hymen with a small 



508 



GYNECOLOGICAL MINOR SURGERY 



opening may cause no difficulty until after marriage, when it interferes 
with coitus. 

Treatment.— As a spontaneous cure is uncertain, early operation is 
indicated in all cases; the extent of the operation depending largely 
upon the location and the extent of the atresia. 

When the hymen alone is involved, a simple incision in the midline 
is all that is required. An anesthetic in these cases is unnecessary. 

The regular menstrual flow tends 
to keep the opening free; but if it 
should become constricted at a 
later date it is a simple operation 
to enlarge the opening. 

When the separation is caused by 
a tissue-diaphragm which may vary 
in thickness from that of the hymen 
up to about a quarter of an inch, 
the opening should be made under 
general or local anesthesia, and the 
mucous membrane of the vagina 
should be pulled down over the 
denuded area and stitched to the 
cut edge of the skin with fine silk. 
In cases where there is more tissue 
to be divided or where the vagina 
is completely absent, the opera- 
tion presents many more difficulties. 
Such an operation should be at- 
tempted only in the hospital with 
the patient under a general anes- 
thetic and therefore its discussion is not part of minor surgery. Even 
in the simplest cases the previous dilatation of the uterus and tubes 
may lead to secondary infection with complicating septicemia. 




Fig. 379. — Absence of external geni- 
tals in a child, aged five years. No 
internal organs found by rectal exami- 
nation. Sex undetermined. 



VULVITIS AND VAGINITIS. 

Simple vulvitis and vaginitis are more frequent in children than they 
are in adults. This is because in the adult the thick epithelium is 
more resistant to bacterial invasion than the thin, delicate epithelium 
of the child. The causes are uncleanliness, irritating urine, or dis- 
charges from lesions higher up in the genito-urinary tract, and the 
irritation due to foreign bodies in the vagina. Thread worms and 
masturbation are said to be common causes in children. In adults, 
diabetes is a common cause. 

Gonorrheal infection is the most common cause of vaginal discharge 
in children. It is very contagious and will sometimes run through an 
entire hospital ward in spite of attempts to control its spread. Gon- 
orrheal infection in little girls is probably spread by infected towels, 



PRURITUS VULVAE 509 

clothing infected in laundries, bed clothing, etc. It is very resistant 
to treatment. Occasionally in poorly nourished children membranous 
inflammation may occur on the vulva and in the lower segment of the 
vagina. It is usually a streptococcus infection and is generally very 
resistant to treatment. True diphtheria of the vulva may occur but it 
is very rare. 

Treatment. —The usual types of simple vulvitis and vaginitis will 
clear up under ordinary forms of cleanliness. The cause (thread 
worms or other form of irritation) should be removed if possible. If 
the urine is highly acid a bicarbonate of soda solution (2 drams to the 
pint) used as a wash and douche will often relieve the symptoms. 
Simple acute vulvitis is often relieved by a dusting powder such as 
borated talcum or by a 2 per cent carbolic acid ointment. 

The gonorrheal form of vaginitis in children is best treated by 
cleansing douches of warm, antiseptic solutions. For details of the 
treatment of acute gonorrhea in the female the reader is referred to 
works devoted to gynecology. In the chronic form of gonorrhea, 
cleansing and astringent douches are valuable. Sulphate of zinc 
(1 grain to the ounce), or potassium permanganate (1 to 5000) are both 
mild astringents, the use of which is followed by favorable results. In 
both forms of inflammation, the local application of a 25 per cent solu- 
tion of argyrol directly to the inflamed area is of undoubted value. 



PRURITUS VULV^I. 

Itching of the vulva is a symptom of many general and local diseases 
which act as excitants of the peripheral nerve endings. In many cases 
the condition begins as a well-defined inflammation but the itching 
persists long after the inflammatory symptoms subside, apparently 
as a simple neurosis. The most common causes are irritating dis- 
charges, highly acid or ammoniacal urine, uncleanliness, animal 
parasites, mechanical irritation, and hyperidrosis. It is frequently 
associated with diabetes. 

Usually the symptoms are worse at night being increased by warmth. 
The disease is aggravated by the continuous scratching which also 
thickens the skin and in time brings about more or less connective 
tissue hyperplasia. 

Treatment.— The causes of the irritation, both general and local, 
should receive appropriate treatment. When there is no apparent 
cause, that is, when the condition is apparently a pure neurosis, the 
parts should be kept scrupulously clean and the irritated surfaces 
should be kept apart by dry cotton or gauze. An ointment of carbolic 
acid and menthol, of each grs. x to the ounce, will often give relief. 
Belladonna ointment and alcohol or ether may be of service. In 
severe cases the vulva may be wiped with pure carbolic acid, which is 
left on for from twenty to thirty seconds and then washed off with 



510 GYNECOLOGICAL MINOR SURGERY 

alcohol or silver nitrate solution (20 per cent) may be applied momen- 
tarily and then washed off with saline. 

In persistent cases the skin may be injected with a weak solution of 
novocain, care being taken to infiltrate the entire area. This procedure 
may be followed by permanent relief. In a few cases operation has been 
necessary. Permanent relief usually follows the division of the sensory 
nerves supplying the region of the vulva. 

We have seen a few cases relieved by injections of 70 per cent alcohol. 
As these injections are very painful they must be combined with an 
injection of novocain. Only small quantities of alcohol must be used, 
as there is danger of necrosis. 

FOREIGN BODIES IN THE VAGINA AND URETHRA. 

Foreign bodies are frequently found in the vagina or urethra. They 
are ordinarily inserted for the purpose of masturbation or in order to 
produce abortion. Occasionally forgotten pessaries covered with 
lime salts are found high up in the vagina. Vesical calculi may be 
stopped permanently in the urethra or find their way into the vagina. 
Catheters are sometimes broken off in the urethra. 

The symptoms due to foreign bodies vary considerably. Usually 
they are well borne at first ; but later, whether in the vagina or urethra 
they become encrusted with lime salts and cause irritation and purulent 
discharge. Usually there is little or no pain. 

Treatment. —The removal of a foreign body from the vagina is com- 
paratively easy. If it lies in the urethra it should be removed under 
direct examination through a urethral speculum. Most bodies which 
have been introduced into the bladder through the urethra can be 
removed through the cystocope; but those that have remained a long 
time become so encrusted with urinary salts that they can be removed 
only by cystotomy. Their early removal is indicated, as otherwise 
they may cause ulceration either into the vagina or rectum. 

ABSCESS OF THE VULVO-VAGINAL GLANDS. 

The vulvo-vaginal glands may become inflamed as a result of infection 
transmitted to the gland through the duct. While the most common 
cause of inflammation is the gonococcus, other organisms may act as the 
exciting agent. They occur as tumors at the lower part of one or both 
labia, the mouth of the duct having the appearance of a small red 
papilla. When pressure is made upon the gland there may be a scanty 
mucopurulent discharge from the duct. If the duct is occluded the 
gland appears as a tender, elastic tumor. When the inflammation is 
acute there is likely to be severe pain which may be severe enough to 
confine the patient to bed. 

Treatment.— In mild cases the duct may be dilated with a blunt 
probe and the contents squeezed out with slight pressure- It is 



VULVO-VAGINAL CYST 



511 




occasionally possible to insert a blunt hypodermic needle into the duct 
and to inject the inside of the gland with an argyrol or a weak iodine 
solution. This treatment repeated once or twice daily, combined with 
hot sitz-baths and hot applications, may relieve the milder cases. 

In acute cases in which there is considerable, surrounding inflam- 
mation and induration, the duct is usually occluded and the patient 
is in great pain. In such cases the 
abscess should be incised under 
local anesthesia, the abscess-cavity 
being swabbed with pure carbolic 
acid and the wound packed with 
sterile gauze and allowed to heal 
by granulation. Healing is usually 
complete in about two weeks, but 
recurrences after this method of 
treatment are not uncommon. 

For the recurrent cases and the 
subacute cases, excision is the 
method of choice. The gland 
should be completely removed 
through an incision upon the skin 
surface of the labia. After the 
incision has been deepened down 
to the gland capsule, slight pres- 
sure is made and the gland bulges 
up through the wound. It can 
now be dissected loose with the 

handle of a knife or closed scissors. The base of the gland is usually 
rather firmly attached to the bone by fibrous tissue which must be cut 
at this point. After the gland is removed there is likely to be con- 
siderable hemorrhage from the cavity. This can be partially 
stopped by ligating any bleeding point, but there is always considerable 
capillary oozing which can only be controlled by deep sutures so ar- 
ranged as to close in the entire cavity. Drainage is not required. 




Fig. 380. — Abscess of Bartholin's 
gland. Left. 



VULVO-VAGINAL CYST. 

It sometimes happens that the duct of the vulvo-vaginal gland 
becomes obstructed even in the absence of inflammation. The gland- 
cells continue to secrete and the result is a spherical tumor which is 
usually tense and elastic. In some cases the cyst may continue to 
increase in size until it is as large as an egg or even larger, showing as a 
thin-walled tumor covered by normal skin which is freely movable. 
The cyst itself is likely to be attached to the deeper parts. There is 
rarely any pain, but by its size alone the tumor may cause annoyance 
and require removal. After existing for a long period without symp- 
toms, the cyst may become infected and an abscess result, 



512 GYNECOLOGICAL MINOR SURGERY 

Treatment. —An attempt may be made to reestablish the patency of 
the duct by making a small incision at the location of the mouth of the 
duct and draining it with a small, rubber, tissue drain until the sinus is 
lined with epithelium. This method, as a rule, is rather unsatisfactory. 
The better method is complete excision of the sac as described above 
in the treatment of subacute infection. 

ULCERATION OF THE VULVA. 

There are several different ulcers which may occur upon the vulva. 
Those commonly found are: (1) Simple ulcer; (2) chancroid; (3) 
chancre; (4) lupus; (5) epithelioma. 

Ulcers occur on the labia or at any point about the entrance to the 
vagina. Any of the above-named ulcers may occur in the vagina or 
on the cervix, and in this latter position they are frequently overlooked. 
Owing to the fact that the parts about the vulva are in constant 
apposition and are subject to the irritation of the urine, leucorrheal 
and menstrual discharges, even the simpler forms are much more 
difficult to cure than are similar ulcers in other parts of the body. 

Simple Ulceration.— Simple ulceration follows irritation due to 
scratching in pruritis or from uncleanliness. Slight abrasions may 
develop into severe ulceration in the presence of an infectious leucor- 
rheal discharge. 

Treatment. —The treatment is cleanliness with local antiseptic appli- 
cations. In cases of persistent ulceration resembling lupus, even if 
there is no distinct evidence of tuberculosis, it is advisable to excise 
the ulcer rather than to continue conservative treatment. 

Chancroids.— Chancroids occur about the entrance to the vagina 
and usually show a punched-out appearance, the edges of the ulcer 
being considerably undermined. There is a purulent discharge which 
is highly infectious ; and secondary infections, as a consequence, are of 
quite common occurrence. The incubation period is usually five or 
six days. 

Treatment. —As soon as the diagnosis of chancroidal ulcer is made, 
each individual ulcer should be thoroughly cauterized with either 
pure carbolic acid or nitric acid. This should be done most carefully, 
each ulcer being separately treated. If the vagina or cervix is affected, 
it should be cauterized in the same manner. Following cauterization, 
an antiseptic douche should be given and the vagina, and vulva well 
dried and powdered with a mixture of calomel and talcum (equal 
parts), iodoform, aristol, or other antiseptic powder. The lips of the 
vulva are then separated with sterile gauze or cotton which is held on 
with a T-bandage. In some cases this form of treatment can be 
performed without anesthesia; in other cases, local anesthesia is neces- 
sary; while, in extensive ulcers, satisfactory results can only be obtained 
by the use of a general anesthetic. Douches should be given twice 
daily until all evidences of infection have disappeared and the ulcers 



ULCERATION OF THE VULVA 513 

are filled with healthy granulations. After each douche the parts 
should be well dried and dusted with powder as described above. 

If the pain is very severe, hot fomentations may be necessary for a 
time in order to give relief. As the ulcer begins to show healthy 
granulations, a stimulating application, such as balsam of Peru or 
red wash, may hasten the process of healing. Exuberant granulation 
should be snipped away with scissors or touched with silver nitrate. 

Patients suffering from chancroids may show anemia and malnutri- 
tion. In such cases general tonic and dietetic measures are indicated. 
In complicating inguinal adenitis, or bubo, ichthyol is indicated as a 
local application before suppuration occurs. Later, when pus-forma- 
tion is evident, incision or excision is required. 

Chancre. — The primary lesion of syphilis occurs in the same loca- 
tions as chancroid. The syphilitic infection finds its point of entrance 
in a superficial abrasion of the epithelium. The abrasion may become 
infected with ordinary pyogenic bacteria, a small ulceration resulting 
which becomes secondarily infected with syphilis. These cases slowly 
change in their characteristics from a simple ulcer to one that is 
definitely a chancre. In other cases after infection with spirochseta 
the abrasion may heal without signs of inflammation. The lesion then 
begins as an area of infiltration in the skin without distinct ulceration. 
Later, the epithelium becomes eroded and an ulcer results. The initial 
lesion of syphilis in the female may show the same variations in size 
and shape as are seen in the male. The microscopic demonstration 
of the Spirochaeta pallida makes certain the diagnosis. 

The incubation period of a chancre is from two days to two weeks; 
occasionally it is considerably longer. 

In secondary syphilis, mucous patches are seen about the vulva, 
often associated with venereal warts. Gumma of the vulva is very 
rare. 

Treatment. —The treatment is the same as in the male except that 
it is necessary to use more care in the hygiene of the genitals of the 
female because, the parts being in apposition, infectious discharges 
are likely to lead to severe inflammation and secondary areas of 
infection. 

Lupus.— Tuberculosis of the vulva or of the vagina is a rare disease 
and is generally secondary to tuberculosis in some other part of the 
body, usually the bladder or kidneys. It begins as a dark, reddish 
area of infiltration which after several months shows areas of ulceration. 
Owing to the fact that the surfaces are usually moist the ulcer takes on 
a grayish, unhealthy appearance. The course, similar to lupus else- 
where, is of long duration. There is slow extension over a period of 
years, followed by cicatrization. 

Treatment.— The treatment is the same as for lupus in other parts 
of the body. If seen early, extirpation is advisable, otherwise the 
treatment is limited to cauterization, roentgen rays, and the Finsen light, 

E'pitheliomata are discussed under malignant tumors, 



514 GYNECOLOGICAL MINOR SURGERY 

VAGINISMUS. 

Hyperesthesia of the vulva and vagina, associated with an abnormal, 
spasmodic action of the muscles of the pelvic floor, is known as vaginis- 
mus and occurs as a rule in hysterical or neurasthenic patients. In 
some cases a painful fissure of the vulva or vagina, or painful lesions 
of the vagina, urethra, vulva, or rectum, apparently act as the exciting 
cause. 

The patient usually applies to the surgeon because coitus is painful 
or unbearable. Douching and examination may excite the same 
spasm, the contraction being so severe at times as to cause the patient 
to cry out with pain. Attempts at examination are resisted, the 
patient becomes nervous and hysterical so that a thorough examination 
may be impossible except under anesthesia. When an anesthetic is 
given, the spasm relaxes and it is not unusual to find little or nothing 
to account for the pain. 

Treatment.— This should consist of the treatment of the cause if any 
can be found, together with measures to diminish the local hyper- 
esthesia. Tonics, laxatives, sitz-baths, and general hygienic measures, 
all have a certain beneficial influence. If persistent fissures or ulcers 
are present they should be excised. If small tumors or cysts are found 
they should be excised. Forcible dilatation and rupture of the hymen 
under anesthesia have been found valuable in some cases. After dilata- 
tion, a glass vaginal dilator should be worn for a few hours daily. 
This the patient applies herself, the dilator being covered with oint- 
ment and inserted while the patient is in the recumbent position. 
Occasionally, infiltration of the entrance to the vagina with weak 
cocain solution has been found of value. 

COCCYGODYNIA. 

This is another condition closely allied to the above which is likely 
to occur in hysterical or nervous women. In this condition the pain is 
referred to the region of the coccyx and any force which moves the 
coccyx causes acute pain. Thus the patient has pain on defecation, 
on sitting down, and during coitus. Fracture and dislocation of the 
coccyx, fissure of the anus, and reflex nervous disturbances, especially 
those due to ovarian disease, are commonly considered as exciting 
causes. 

Treatment. —The treatment may be palliative or radical. The 
palliative treatment consists of the cure of any local fissure or ulcers 
together with counter-irritation and sedative measures. A rectal 
suppository of belladonna or hot sitz-baths may be found beneficial. 
Infiltration of the surrounding area with weak cocaine has been advised. 

Radical treatment, besides removing any uterine or ovarian trouble 
which may exist, consists of the choice of one of two operations : First, 
the muscles attached to the coccyx may be divided ; second, the entire. 



BENIGN TUMORS OF THE VULVA AND VAGINA 



515 



bone may be excised. Section of the muscles is best accomplished 
by a median incision which allows the skin to be reflected laterally, 
thus exposing the muscles, which are then divided with a pair of 
scissors along both sides of the bone. The wound is closed with silk 
sutures. Simpson has recommended the use of a tenotomy knife with 
which the same operation can be accomplished subcutaneously. 
However, the subcutaneous method is more dangerous and less certain 
than is the open method. 

Excision of the coccyx is the operation of choice when the coccyx is 
diseased, or when, following fracture or dislocation, it becomes fixed 
in malposition. The bone should be exposed by a median incision and 
the attachments should be divided with heavy scissors. The bone is 
disarticulated with a knife or a pair of bone-cutting forceps, and the 
wound is closed with silk or silkworm gut sutures. In some cases the 
pain persists even after the above operation has been successfully 
carried out. 




Fig. 381. — Small hard spicule presenting above clitoris in a girl, aged eight years; 
watched for few weeks, doubled in size; operation refused. Probably a chondroma grow- 
ing from symphysis. 



BENIGN TUMORS OF THE VULVA AND VAGINA. 

The various tumors which occur in other parts of the body are found 
about the vulva and vagina. Special tumors, which on account of 
their frequency or special significance acquire increased importance 
in this location, will be discussed in detail. 

Hydrocele of the Labium.— This condition corresponds to what is 
termed in the male a hydrocele of the cord. It is a collection of fluid 
in the canal of Nuck (the prolongation of the peritoneum along the 
round ligament). It usually connects with the general peritoneal 
cavity, but it may be closed at the upper end. If open at the upper 
end it is practically a hernial sac and should be treated as such. If 
closed above, it should be excised in the same manner as hydrocele of 
the cord in the male. 

Venereal Warts.— Condylomata, or venereal warts, frequently occur 
about the viilva. What has been said in reference to venereal warts 



516 



GYNECOLOGICAL MINOR SURGERY 



in the male as regards etiology, diagnosis, and treatment, applies equally 
to the female. Because of the size of the surfaces which are kept moist 
and irritated with the discharge the masses of condylomata about the 
vulva are likely to become extensive. 




Fig. 382. — Syphilitic condylomata of the anus. 

Lipoma.— Occasionally, a lipoma occurs in the region of the labia. 
If the condition involves both sides it must be differentiated from 
elephantiasis. Removal by operation is the only satisfactory form of 
treatment. 

Fibroma.— Fibroma or myofibroma may develop in the vulva or in 
the vagina. These tumors are often pedunculated, forming a polypus. 
The non-pedunculated variety should be enucleated ; the wound being 
sutured after the hemorrhage has been controlled. Polypoid growths 
should be amputated, the bleeding stopped, and the skin or mucous 
membrane sutured. 



MALIGNANT TUMORS OF THE VULVA AND VAGINA. 

Epithelioma.— This disease usually begins as a small nodule generally 
on the inner side of the labium. This slowly increases in size, giving 
few or no symptoms until after several months the surface ulcerates, 
The ulcer now becomes more or less indurated and there is a thin, foul 
discharge. Involvement of the lymph nodes in the groin occurs early. 

Carcinomata of the medullary or scirrhus types are extremely rare 
about the vulva as are all primary cancers of the vagina. Carcinomata 
of the uterus are common, 



VAGINAL CYSTS 517 

Treatment. —The treatment is early and complete excision together 
with the removal of the regional lymph nodes. The prognosis is 
uniformly bad. Permanent cures are very rare. Recently favorable 
results have been reported after treatment with radium. 

Sarcoma.— Sarcomatous tumors are very rare about the vulva and 
vagina. When they occur, they usually appear at an earlier period 
than do carcinomata. Sarcomata are said to occur in children and in 
adults both in the vagina and upon the vulva, but they are very rare. 
Early excision is indicated in all cases. 

Treatment of Inoperable Cases.— If possible, roentgen ray and radium 
therapy should be tried in every case where operation is not advisable. 
If these are not available, measures may be taken to control the foul 
discharge and the constant bleeding. These measures consist of 
surgical cleansing of the ulcerated surface so as to remove all foul 
discharge, and the application of the actual cautery at red heat to cause 
the partial destruction of the mass. The wound is dusted with an 
antiseptic powder and a dry dressing is applied. Inoperable cases 
may be kept for a time in comparative comfort, if this treatment is 
carefully carried out. 

URETHRAL CARUNCLE. 

A small, connective tissue tumor occurring at the mouth of the 
urethra is known as a urethral caruncle. It consists of fibrous tissue 
and many small bloodvessels. In addition it contains many nerve 
fibers, in consequence of which the tumor is often very tender. There 
may be acute pain on urination and during coitus. Even the slightest 
touch may cause severe pain. The tumor usually occurs at the mouth 
of the urethra; but cases have been reported where it is wholly inside 
of the urethra. The growth is bright red in color, covered with 
epithelium, and often pedunculated. 

Treatment.— The treatment is complete extirpation. The mucous 
membrane should be reflected from the base after preliminary dilatation 
of the orifice of the urethra. After the mucous membrane has been 
reflected, the growth is cut away and the bleeding points caught and 
ligated. The incision in the mucous membrane is then carefully 
sutured together. Unless completely excised, the urethral caruncle 
is likely to recur. 

VAGINAL CYSTS. 

Small cysts in the wall of the vagina may result from dilatation of the 
vaginal glands, from epithelial nests buried in scar tissue after operation 
or injury, or from the remains of Gartner's ducts. The contents of the 
cyst may become infected, resulting in an abscess. 

Treatment.— Small cysts should be excised unopened; while larger 
ones may be incised and the sac dissected out, the wound being closed 
without drainage. Infected cysts should be opened and packed with 
gauze until the surrounding inflammation has subsided, when the 
remains of the cyst may be removed. 



CHAPTER XX. 
BANDAGING. 

Bandages are used to secure splints, to retain dressings, to make 
pressure for the control of hemorrhage and for the correction of deformi- 
ties, and to protect and support any part of the body. Bandages 
may be made of muslin, gauze, linen, flannel, rubber, paper and other 
similar materials. For most practical purposes muslin and gauze 
bandages will fill all requirements. Muslin offers a firm inelastic 
material which is most useful for the application of splints or for 
support or protection. Gauze is soft and elastic and is better adapted 
for retaining wound dressings. The Esmarch bandage, the common 
form of rubber bandage, is generally used where firm pressure is desired. 
Crepe paper bandages, recently introduced to replace gauze, are light 
and cheap but are easily torn when wet and consequently unsuited for 
dressings apt to become moistened with discharge. They are readily 
sterilized and are to be recommended for use in special cases. Flannel 
bandages are both firm and elastic and are useful for application where 
gentle, even pressure on the skin surface is desired. 

Bandages may be treated with starch or plaster in order to make them 
firmer. Plaster bandages become board-like when dry, but starch 
bandages are less stiff and are useful where only partial fixation is 
required. Plaster bandages are described in the treatment of fractures ; 
starch bandages are made by dipping a very loosely rolled bandage into 
a solution of hot starch. The stiffness of the starch bandage can be 
varied according to the strength of the starch solution. 

The Roller Bandage.— The ordinary bandage used by the medical 
profession is the so-called roller bandage. It comes in different widths, 
ordinarily from one inch to five or six inches, and is usually about ten 
yards long. The one-, two-, and three -inch bandages are the widths 
commonly used. 

The roller bandage is best made when rolled by machinery, but in 
an emergency may be rolled by hand. Surgical supply houses are able 
to supply gauze bandages, ready sterilized and wrapped, for little more 
than they could be prepared at home. Owing to the elasticity of the 
ordinary gauze it is very difficult to make a neat roller by hand and 
except in extraordinary circumstances it is a waste of time. Muslin 
may conveniently be rolled at home with a hand roller bandage 
machine, which can be purchased at a moderate price. 

In certain cases it may be necessary to roll a bandage by hand. 
It is important that the first few turns be rolled very tightly. The roll 
is started by turning the end of the bandage on itself for about six 
inches, and then with the fingers rolling the end until a small firm roll 



CIRCULAR BANDAGES 519 

is obtained of sufficient size to allow its being grasped between the 
thumb and index finger of the left hand. It is held in this position 
while the loose end is held firmly between the thumb and index finger 
of the right hand, in such a manner as to guide the winding of the roll. 
The right hand moves from pronation to supination, winding a half- 
turn of the bandage in the movement. The hold with the left hand is 
relaxed and the right hand returns to pronation carrying the bandage. 
The ends of the bandage are again grasped in the left hand and the 
movement is repeated. With a little practice a very satisfactory 
bandage may be obtained. However, the method is slow and in 
general inferior to the use of a machine. 

Gauze bandages will be found most convenient for use about the 
head and neck and for the fingers and toes. For the trunk and limbs 
there are many occasions when the heavy, unbleached muslin bandages 
may advantageously be used. 

Application.— Bandages should always be applied smoothly and 
neatly with even parallel borders. Pressure should be firm, equal on 
both edges, and not sufficient to cause constriction. 

In bandaging some wounds and in the application of wet dressings 
to infected areas, it is often impossible to secure a dressing which is 
either neat or smooth. In such cases, if the general principles of band- 
aging are remembered, a bandage may be applied which will hold the 
dressing and remain in place, although it has no resemblance to typical 
bandages described in text-books. 

In certain parts of the body, for example, the nose, about the mouth, 
etc., all bandages are unsatisfactory, and adhesive plaster holds a 
dressing in place much better. About the mouth, where dressings 
become wet with saliva, we prefer to do away with the dressing entirely 
whenever possible, allowing the blood and serum to dry over the line 
of suture and form a natural protection for the wound. 

In applying a roller bandage a few inches of the bandage is unrolled 
and the loose end is taken in the left hand while the roll is held in the 
right. The outer side of the bandage is then placed over the dressing 
or splint and the bandage is carried around the part from left to right, 
making a single circular turn which anchors the bandage. The process 
is then continued either in a circular or oblique direction until the 
bandage is completed. The end is fixed with a pin or a strip of adhesive 
or in some cases by sewing the loose end to the previous turns. Fixa- 
tion may also be secured by tearing the end of the bandage in a longi- 
tudinal direction for six or eight inches, forming two tails, one of which 
is passed backward around the limb and tied on the opposite side. 
This results in a knot at the end of the bandage which is neither so 
neat nor so secure as other methods of fixation. 

Circular Bandages.— The circular bandage is the simplest form of 
bandage and is applied where only a limited area needs to be covered. 
It is most commonly used on the neck, but may be applied about the 
forehead, wrist, ankle, etc. Each turn covers the preceding turn. 



520 



BANDAGING 



Spiral Bandage.— The spiral bandage is fixed by two circular turns 
and is then continued slightly obliquely so as to cover the limb in a 
spiral manner. Each turn overlaps the previous turn about one-half 
to two-thirds. This bandage is applicable to any portion of the body 
where the diameter is uniform. It is used to hold splints and large 
dressings in place. 

The spiral oblique bandage is similar to the spiral but the turns do not 
overlap. It is seldom used except for temporary dressings. The 
bandage lies smoothly against the skin but does not cover the entire 
dressing. In applying a plaster bandage the spiral oblique turns may 
be used advantageously, the bandage being turned on itself and 
additional oblique turns carried in the opposite direction. If this is 
continued the entire limb will finally be covered. In ordinary conversa- 
tion any bandage which consists of circular turns either transverse or 
slightly oblique (spiral) is frequently referred to as a circular bandage. 




Fig. 383. — Spiral oblique bandage. 

Figure-of-eight Bandage.— A considerable portion of the body, 
especially the extremities, is more or less roughly cone-shaped. Thus 
the leg from the calf to the ankle tapers off in the manner of a truncated 
cone, and from the calf to the knee the condition is similar but the base 
of the cone is directed downward, while from the heel to the ankle is a 
cone with the apex upward, and from the heel to the instep, a cone with 
the apex directed forward. Depending on the degree of muscular 
development the extremities represent for purposes of bandaging a 
series of truncated cones and the same condition is seen less obviously 
in other parts of the body. 

If an attempt is made to bandage a truncated cone with a circular 
bandage it will be found that the bandage does not fit snugly. One 
edge will be firm and the other edge will show more or less fullness. 
This condition is seen in the arms and legs, except in very thin indivi- 
duals. In order to overcome this fulness, the direction of the bandage 
may be changed so that both edges fit snugly. In order to accomplish 



SPICA BANDAGE 



521 



this, the bandage must be turned sharply and carried around the limb 
in an oblique direction, several inches above the first turn. It is then 
brought downward and forward so as to cross the first turn and carried 
around behind the limb to the point of starting, forming a figure-of- 
eight. This is repeated, overlapping each turn slightly so as to cover 
the entire part. There will be a little fulness at the back of the upper 
turn which will be covered by the subsequent turns of the bandage. 

Spiral Reverse Bandage. —Another 
method of taking in the slack which 
occurs along one side of a bandage 
applied to a cone-shaped portion of 
the body is the use of the spiral re- 
verse. This consists of a series of 
oblique circular turns in which the 
bandage is turned once upon itself in 
each circular turn about the limb. It 
is generally used on the extremities, 
but is occasionally required in band- 
ages about the head or trunk. In 
making a spiral reverse of the fore- 
arm, which may serve as an example, 
the bandage is fixed by two turns 
about the wrist and a third turn is 
made to run up the forearm so that 
both edges lie smoothly on the fore- 
arm. The lower border in this posi- 
tion will cross the upper border of the 
circular turns about the middle of the 
forearm. While the right hand holds 
the bandage taut the left thumb is 
placed on the point of crossing, hold- 
ing the turn in place. The right hand 

is allowed to relax and the bandage, turned toward the operator through 
an angle of 180 degrees, is passed around the limb and drawn taut with 
the left hand. This results in the first spiral reverse, and the next 
turn repeats the procedure, overlapping the first turn about one-half. 
Each time the bandage reaches the point of crossing the reverse is made 
until near the elbow, where the forearm grows smaller, and the bandage 
is finished by a few circular turns. 

Spica Bandage.— The spica bandage is used over joints such as the 
shoulder, hip and thumb. It represents a figure-of-eight in which the 
two loops are taken about different parts of the body as, for example, 
the trunk and the thigh. The turns are made to overlap in such a 
manner as to cover the dressing. Thus a spica of the abdomen and 
right thigh may be applied so as to cover a wound of the lower part 
of the abdomen or back, the right groin, the right buttock, or the upper 
part of the right thigh. 




Fig. 384. — Progressive figure-of- 
eight bandage. 



522 BANDAGING 

Recurrent Bandage.— A recurrent bandage is formed by turning a 
bandage back and forth on itself over a stump or the end of a finger in 
such a manner that the loops overlap and gradually cover the end of 
the stump or finger. The ends of the loops are held in place by 
circular turns. 

BANDAGES OF THE HEAD AND NECK. 

The Four-tailed Bandage.— This is one of the simplest bandages for 
wounds in the region of the occiput or chin. It is made from a strip 
of muslin four or five inches wide and about a yard long. Both ends 
of the bandage are torn longitudinally for about fifteen inches so that 
there results a small rectangle with two tails on each side. When 
applied for wounds of the occiput, the untorn portion of the bandage 
is placed over the dressing and the upper tails are brought forward and 
fastened beneath the chin, while the lower tails are made to cross the 
upper and are fastened over the forehead. When used on the chin, 
the point of the chin is placed in the center of the bandage, the tails of 
which extend laterally. The upper tails are carried directly backward 
and fastened at the back of the neck, and the lower tails are carried 
directly upward and fastened over the top of the head. To complete 
the bandage, one tail of each set is tied together over the top of the head. 
This maneuver draws the neck portion of the bandage well up upon the 
occiput so that it does not interfere with movements of the neck. 
For wounds on top of the head one pair of tails fastens beneath the 
occiput and the other crosses and is fastened beneath the chin. The 
advantages of the four-tailed bandage are its simplicity and the ease 
with which it may be applied. Its disadvantages are that it is 
insecure and that it cannot be satisfactorily used except in special 
locations. 

Circular Bandage of the Head.— A two-inch bandage is used. This 
bandage may be made to cover any portion of the head between two 
horizontal lines, the lower about one inch below the ear, and the upper 
two inches above it. The bandage begins by two circular turns about 
the occipito-frontal region and is then continued, overlapping slightly 
at the point to be covered. In the occipital region the edges should 
overlap so that the width of the bandage is never less than three and a 
half inches, but in front the turns may lie one upon the other so as to be 
no wider than two inches. The turns of the bandage may pass slightly 
downward or upward so as to cover the ears or eyes or a portion of the 
scalp. When it is desired to cover the whole scalp a square of gauze 
may be placed upon the top of the head. While this dressing is held in 
place two circular turns are taken over it about the occipito-frontal 
diameter of the head. This will leave the points of the gauze square 
hanging down in front and behind and over both ears. These ends are 
turned upward so as to be included in the next turns of the circular 
bandage. 



JBANDAGES OF THE HEAD AND NECK 



523 



In children and restless or delirious patients, it may be necessary to 
anchor the bandage either by a turn under the chin or by one or two 
turns below the ears. We have found it most convenient, in these 
cases, to make two circular turns extending above the right ear and 
below the left, and then two turns above the left ear and below the 
right. When completed, this bandage may be greatly strengthened 
by a single turn of one-inch adhesive plaster extending around the head, 
over the forehead, above the ears, and just below the occiput behind. 

The circular bandage as described above may be made to reverse 
on one side and overlap on the other so as to cover either the eye or ear 
(including the mastoid region) . It may 
be made to cover both eyes or ears by 
first making a reverse on the left side 
and overlapping the bandage on the 
right, and then in the next turn revers- 
ing on the right and overlapping on the 
left. 

Circular Bandage of the Neck.— Dress- 
ings are held on the neck with a few 
circular turns of a gauze bandage. Care 
is always required not to bandage the 
neck too snugly. A degree of constric- 
tion which is unnoticed elsewhere be- 
comes intolerable about the neck. For 
this reason neck bandages should be 
either padded with cotton or applied 
very loosely. When it is desired to 
cover dressings high up on the neck, 

in, for example, boils on the nape of the neck, the turns may be made to 
overlap so as to cover the dressing and may be held up by strips of 
adhesive plaster extending from the bandage to the skin. 

Oblique Bandage of the Eye.— A two-inch bandage is used. For the 
right eye the bandage is held in the right hand and two circular turns 
are made from left to right about the forehead and occiput. The third 
turn carries the roller beneath the right ear, up over the right eye, 
across the opposite parietal eminence and back to the occiput. The 
next turn follows the preceding, overlapping slightly, and the turns 
are continued until the eye is covered. If desired the turns may be 
continued until the ear is also covered. When sufficient oblique turns 
have been applied one or two turns are made about the occipitofrontal 
diameter for security and the end is fixed with adhesive plaster or a pin. 
When it is desired to cover the left eye, the turns are the same except 
that the oblique turns pass downward across the eye and beneath the 
left ear to the occiput. 

Figure-of-eight Bandage of Both Eyes.— This is started exactly as the 
oblique bandage of the right eye, by two circular turns followed by an 
oblique turn ending at the occiput. The next turn covers the circular 




Fig. 385. — Simple circular 
bandage of the scalp. 



524 



BANDAGING 



turn and this is followed by an oblique turn passing downward across 
the left eye and beneath the left ear and ending at the occiput. Another 
circular turn is taken and then an oblique turn over the right eye. 
The bandage is completed by alternate circular and oblique turns. 
If the ears are to be included in the bandage a piece of cotton should 
be placed back of the ear so as to prevent injury from pressure against 
the bone. 




Fig. 386. — Figure-of-eight bandage of both eyes. 

Oblique Bandage of the Ear.— A two-inch bandage is used. For the 
right ear, two circular turns are taken about the occiput and forehead. 
The third turn deviates slightly downward from the occiput and covers 




Fig. 387. — Oblique bandage of the ear. 



the upper part of the right ear and extends obliquely upward to cover 
the circular turn in front. The next turn extends obliquely to cover a 
greater portion of the right ear, but returns each time to coincide with 
the circular turns on the left. When the ear is completely covered the t 



BANDAGES OF THE HEAD AND NECK 



525 



bandage is made secure by one or two circular turns. It will be found 
that it is very difficult to apply this bandage without covering the right 
eye so as partially or completely to obscure the vision. In order to 
remedy this a small strip of narrow bandage may be passed beneath 
all the turns over the right temple. If this is tied in such a way as to 
draw the turns together at this point, the obstruction to vision will be 
removed. This dressing will be found to be more comfortable and to 
hold more satisfactorily if the ear dressing is well covered with cotton 
before the bandage is applied. 




Fig. 388. — Double-recurrent bandage of the head. 



Recurrent Bandage of Head.— This is made with two bandages, a 
one-inch bandage for circular turns and a two -inch bandage for recur- 
rent turns. The wider bandage is started on the occiput and carried 
forward to the forehead and held in place by the narrow bandage which 
is passed around the head just above the ears. The wider bandage 
now passes backward to the occiput where it is held by a circular turn 
and then passes back to the frontal region, and is caught again by a 
circular turn, this process being repeated until the head is covered. 
Thus, the wider bandage is continually passing back and forth, while 
the narrow bandage makes only circular turns. The recurrent loops 
are made to overlap so that the entire scalp may be covered. Where 
speed is necessary the second bandage may be dispensed with, the ends 
of the recurrent loops being held by an assistant until the scalp is 
covered. Two or three circular turns made about the head to include 
all the loops complete the bandage. While less firm than when two 
bandages are used, under ordinary circumstances this latter bandage 
fulfils all requirements. 

Figure-of-eight of Neck and Forehead.— A two-inch bandage is used. 
The first turn passes around the occiput and forehead and the second 



526 



BANDAGING 



around the neck. The turns are repeated alternately until sufficient 
bandage is applied. This will cover a wound high on the neck above 
the hair line, or a circular bandage with a lateral reverse may be used 
for the same purpose. The figure-of-eight of the forehead and neck 
may be combined with a circular bandage of the neck for wounds 
situated low on the back of the neck. 

Bandage of the Cheek.— A two-inch bandage is used and started 
just above the left ear, if the left side of the cheek is to be covered. 
It is fixed by two turns about the occiput and forehead and the third 
turn is carried from the occiput below the ear on the right side, under 
the chin and upward across the left cheek to just behind the orbit, to 
the top of the head and then downward back of the right ear to a point 
beneath the chin. The vertical turns are repeated three or four times, 
each turn on the left cheek overlapping the previous turn until the 

cheek is covered . The last vertical 
turn is pinned where it crosses the 
horizontal turns just above the 
right ear and reversed so as to 
coincide with the occipitofrontal 
portion of the bandage and con- 
tinued two or three times around 
the head . The circular turns about 
the head serve to hold the vertical 
turns in place. Pins may be placed 
at the crossings for additional se- 
curity. 

Barton's Bandage. —A roller about 
two inches wide and about five 
yards long is used. The bandage 
starts over the occiput, passes over 
the right parietal bone across the 
top of the head, vertically down the 
left side of the cheek in front of the ear, under the chin, and vertically 
upward in front of the right ear to the vertex and then downward and 
backward across the left parietal bone to the occiput. From this point 
it is continued forward beneath the right ear across the point of the 
chin and then backward beneath the left ear to the point of origin. 
It may be reinforced by repeated turns. It is used for fracture of the 
jaw or wounds over the chin. Gibson's bandage is somewhat similar 
to Barton's bandage and is used for the same purpose. It is a combina- 
tion of a figure-of-eight bandage of the chin and forehead, the loops 
crossing just beneath the occiput, and a vertical bandage about the 
head in front of the ears. The crossings are pinned. An additional 
strip may be placed in the midline passing from the occiput to the fore- 
head being pinned to the turns where it crosses them, 




Fig. 389. — Showing the four turns of 
a Barton bandage. 



BANDAGES OF THE UPPER EXTREMITY 



527 



BANDAGES OF THE UPPER EXTREMITY. 

Spica of the Shoulder.— A three-inch bandage is used. The end is 
anchored by two or three turns about the arm close to the axilla. The 
bandage then passes in front of the arm and chest to the opposite 
axilla, across the back to the starting place, around the arm again, 
across the chest a little higher than the previous turn, to the axilla, 
and so on repeating the turns. Each turn around the arm mounts 
slightly higher and overlaps the previous turns on the chest and back. 
In the opposite axilla the turns coincide. This is termed an ascending 
spica of the shoulder. 




Fig. 390. — Spica bandage of the shoulder. 

A descending spica may be applied by starting the first turn as 
above, but instead of carrying the first body turn in front of the arm 
and chest, it is carried up over the shoulder and then across the front 




Fig. 391. — Supporting spica bandage of the arm and shoulder. 

of the chest to the opposite axilla upward across the back, over the 
shoulder, around the arm and so on, gradually covering the shoulder 
from above downward. The spica of the shoulder is used for wounds 
in the upper part of the arm and the point of the shoulder . The ascend- 



528 



BANDAGING 



ing bandage is the most satisfactory. As these bandages are intended 
for ambulatory dressings, the lower edge of the bandage should not 
extend below the axillary fold on the bandaged side. Otherwise the 
bandage will slip as soon as the arm is moved. 

Figure-of-eight of the Axilla is used for holding dressings in the 
axilla. A three-inch roller is used starting in the axilla of the well 
side and continuing across the front of the chest to the shoulder, then 
downward behind the shoulder to the axilla, forward under the armpit 
and in front of the shoulder to cross the first turn above the joint, 
then across the back to the opposite axilla. These turns are repeated 
and the ends fixed with safety-pins. Instead of passing to the opposite 
axilla the turns may be taken about the neck, forming a combination 
bandage for the neck and axilla. 





Fig. 392. — Velpeau's sling of the arm. 



Fig. 393.— Modified Velpeau's band- 
age of the arm. 



Velpeau's Bandage.— This bandage is used to fix the shoulder and 
requires two three-inch rollers, or a single roller about ten yards long. 
The patient is placed with the fingers of the injured arm on the clavicle 
of the well side. Gauze or cotton is placed in the axilla and under the 
arm to prevent the contact of the skin surfaces which is certain to cause 
irritation. The Velpeau bandage is applied as follows: Standing 
facing the patient, the operator holds the bandage in the hand opposite 
the injured side, and with the other hand holds the free end against the 
chest of the well side. The bandage is carried toward the injured side, 
crossing the middle of the arm, and is then carried across the back to 
the starting point. This first turn about the chest and arm anchors 
the bandage. The next turn passes obliquely across the chest to the 
injured shoulder, crossing the shoulder near its tip and passing down 
the back of the arm to the elbow, beneath the elbow, and up in front 
of the arm to the shoulder again ? crossing the previous turn, From 



BANDAGES OF THE UPPER EXTREMITY 529 

this point the bandage is carried obliquely across the back of the chest 
on the uninjured side at a point on the level of the injured elbow. From 
this point a circular turn is made about the body, including the injured 
elbow, bringing the bandage again to the chest on the uninjured side. 
From here the bandage is carried to the injured shoulder, down in back 
of the arm, up in front of the arm to the shoulder again, and then 
obliquely across the back to the starting point, following the previous 
similar turn and overlapping it about one half. The next turn is a 
circular turn slightly higher than the previous one, followed by a 
chest — shoulder — elbow — shoulder — chest turn . 

It will be seen that this bandage consists of two distinct elements: 
A circular turn about the chest and injured arm, and a figure-of-eight 
turn with the crossing on the shoulder (one loop about the chest and 
the other longitudinally about the injured arm). The circular turns 
gradually pass upward and the loops about the arm gradually pass 
inward, covering the entire forearm and chest. The hand is usually 
left free. 

Desault's Three-roller Bandage.— This consists of three separate rol- 
lers two and a half inches wide. The first roller is a spiral bandage of 
the chest and is used to hold an axillary pad in place on the injured 
side. A turn over the sound shoulder may be used in this bandage 
in order to prevent the bandage from slipping down. The second roller 
bandages the injured arm against the chest over the axillary pad. An 
ascending spiral bandage is used for the second roller. If it is made 
firm over the lower part of the arm the axillary pad will act as a fulcrum 
and the tendency to inward deformity which occurs with fractured clav- 
icle will be overcome . The third r ol ler is begun in the axilla on the sound 
side, is passed obliquely across the front of the chest to the shoulder, 
over the shoulder and downward back of the arm to the elbow and 
upward across the forearm to the starting point. From here it con- 
tinues beneath the axilla and upward across the back to the injured 
shoulder, over the shoulder and downward in front of the arm to the 
elbow, beneath the elbow and across the back to the axilla of the sound 
side. The third roller will be seen to consist of a figure-of-eight with 
the crossing point in the sound axilla. One loop comes around in front 
of the chest and is looped back of the arm, the other passes back of the 
chest to be looped in front of the arm. Where the bandages cross they 
should be pinned or sewed together. The dressing is completed with 
a sling about the wrist. 

Bandage of the Finger. —This bandage covers the whole finger includ- 
ing the tip. A narrow roller is used (one inch) . Two or three turns are 
taken around the finger over the second phalanx to anchor the bandage 
and the roller is turned at right angles and carried across the end of the 
finger in recurrent folds, the loops being held with the fingers of the 
left hand. When the recurrent loops cover the tip of the finger the 
roller is again turned at right angles and a circular turn made to hold 
the loops in place. The bandage is then continued up the finger as a 
34 



530 



BANDAGING 



spiral reverse, to end at the base of the finger. This bandage, unless 
very carefully applied, is liable to slip and is not suitable except where 
the dressing is very small. 

A better place is to fix the finger bandage by a loop about the wrist. 
A wider roller is used (two inch) . The bandage is started by two turns 
about the wrist and then carried downward across the back of the hand 
to the finger and around the finger by two or three oblique turns to the 
tip, which is covered by two or three recurrent loops. A single turn is 
taken about the end of the finger to hold the loops, and the bandage is 
carried upward, either as a spiral bandage or as a spiral reverse, to the 
base of the finger. It then passes obliquely across the dorsum of the 
hand and is fixed by one or two turns about the wrist. The turns about 
the wrist serve to anchor the bandage firmly and prevent it slipping 
from the finger. 

Gauntlet Bandage.— A one- or two-inch bandage may be used. The 
bandage is started by two turns about the wrist and is carried across the 

dorsum of the hand to the little finger 
and down the finger to the tip. The 
finger bandage is completed by a spiral 
or a spiral reverse and when the base of 
the finger is reached the bandage is 
carried across the hand to make a single 
turn about the wrist. It then passes to 
the ring-finger which is covered in the 
same way as the little finger and the 
bandage is again returned to the wrist. 
The same process is continued until 
the remaining fingers and the thumb 
are covered and the bandage is ended 
by two or three turns about the wrist. 
This bandage is suitable for holding 
dressings on the fingers and the back of 
the hand. The palm is left uncovered. 
Demi-gauntlet Bandage.— This band- 
age is exactly like the preceding ex- 
cept that the fingers are uncovered. The bandage starts around the 
wrist and is carried to the base of the finger where a single turn is taken 
and the bandage passes back to the wrist. A single turn is taken about 
each of the fingers and the thumb, alternating each finger loop with a 
single turn about the wrist, thereby covering the dorsum of the hand. 
This bandage is of value in applying a dressing to the dorsum of the 
hand when it is desirable to leave the palm and fingers free. The 
reverse demi-gauntlet is applied in the same manner except that the 
crossings are made on the palm of the hand and the dorsum is left free. 
Spica of the Thumb.— A one- or two-inch roller is used. The band- 
age, begun by two turns about the wrist, is carried obliquely across the 
hand to the end of the thumb, where a single circular turn is made, 




Fig. 394. — Gauntlet bandage. 



BANDAGES OF THE UPPER EXTREMITY 531 




Fig. 395. — Method of starting a thumb bandage. 




Fig. 396 




Fig. 397 
Figs. 396 and 397, — Two stages in a hand and thumb bandage. 



532 BANDAGING 

and is then carried obliquely to the wrist, around the wrist and back 
to the thumb. The bandage consists essentially of a figure-of-eight 
with one loop about the wrist, the other about the thumb and the 
crossings on the dorsum of the thumb. The end of the bandage is 
made fast with two circular turns about the wrist. In a similar band- 
age the turns may be made to include the hand rather than the thumb, 
the crossings being either in front or behind, as desired. 




Fig. 398. — Thumb bandage, finished. 




Fig. 399. — Spica of the thumb. 

Figure-of-eight of the Elbow.— Under ordinary circumstances the 
elbow should be bandaged so as to allow movement. A two-inch 
roller is used, and the bandage should be applied with the elbow parti- 
ally flexed. Two turns are made about the forearm below the elbow. 
The third turn passes obliquely across the flexor surface of the joint, 
around the arm above the elbow and obliquely downward again in 
front of the elbow to the starting point. The turns are overlapped 
first about the forearm and then about the arm, gradually converging 
toward the elbow. The point of the elbow is covered last. 

Some surgeons prefer to apply the elbow bandage in the reverse 
direction, as follows : The elbow being held in partial flexion a double 
turn is made directly over the joint of the elbow and exactly at the 
flexure of the joint. The third turn passes obliquely slightly upward 
so as to overlap the previous turn about one-half on the extensor 
surface, then passes forward and obliquely downward crossing the 



BANDAGES OF THE LOWER EXTREMITY 



533 



flexure of the joint to pass around the forearm just below the elbow. 
The turns alternate first above and then below the joint as above 
described, except that the turns progress from the center instead of 
toward it. The end of the bandage may be fixed by one or two turns 
or it may be continued up the arm. 




Fig. 400. — Descending figure-of-eight bandage of the arm or leg. 

Bandage of the Upper Extremity.— A two-inch roller is used. The 
bandage is begun by two turns about the wrists, then passes downward 
to the fingers where a single turn is taken, and is then carried back to 
the wrist. It is again carried to the hand overlapping the first turn and 
back to the wrist. These turns are repeated until the hand is covered 
and the bandage is then carried up the forearm either by spiral reverse 
or figure-of-eight turns. The elbow is covered by figure-of-eight turns 
and the bandage continued as a spiral reverse or figure-of-eight of the 
arm. It may be completed by two circular turns around the arm or 
continued as a spica of the shoulder. 



BANDAGES OF THE LOWER EXTREMITY. 

Spica of the Groin.— A roller bandage three to five inches wide is 
required. The end of the bandage is placed anteriorly over the upper 
third of the thigh. For the right side, the bandage starts over the 



534 



BANDAGING 



dressing on the injured groin toward the uninjured side, passing above 
the iliac crest and then obliquely about the trunk to the starting point. 
From here it is continued in an oblique direction to the inner side of 
the thigh and then passing behind the thigh it inclines obliquely, to 
return again to the starting point. The turns are continued until the 
groin is covered, the crossings of the bandage being located over the 
dressing. For the left side, the direction of the bandage is reversed. 

This is the simple spica of the groin which consists essentially of a 
figure-of-eight with one loop about the pelvis and the other about the 
thigh. For some purposes it may be modified by starting the bandage 
by two or three circular turns about the thigh and finishing it by a few 
turns about the pelvis or w T aist. 





Fig. 401. — Spica bandage of the groin. 



Fig. 402. — Spica bandage of both 
groins. 



Descending Spica.— This is similar to the preceding, except that the 
highest turn is placed first and the turns extend gradually downward. 
The turns overlap about one-half or two-thirds. 

Both the ascending and descending bandages are used to hold dress- 
ings on the groin, upper thigh, and lower abdomen, and occasionally 
for the retention of femoral and inguinal hernia. It is also valuable 
for support in cases of painful hip, as a result of chronic arthritis or 
other cause. A flannel bandage of this sort firmly applied is often 
exceedingly grateful to patients suffering from muscular pains in this 
region, permitting them to be up and at work with little discomfort. 

As the bandage tends to become loosened and to slip out of place, 
all points of dressing should be firmly fixed with pins or adhesive plaster. 
In applying the spica it is a good general rule always to start the 
bandage over the dressing, passing from this point to the waist line on 
the opposite side above the iliac crest. 

Spica of the Buttock. —This bandage is similar to a spica of the groin, 
except that the surgeon stands behind the patient while applying it, 



BANDAGES OF THE LOWER EXTREMITY 535 

thus making the cross-weaving occur posteriorly. For the left side, 
the bandage is begun on the left buttock by one or two turns and is 
then carried obliquely across the sacrum above the iliac crest, and 
obliquely across the lower abdomen to the starting point and continued 
with a turn about the thigh. For the right side, the first turns are made 
from right to left instead of from left to right, as ordinarily. This 
bandage is used to hold dressings on the buttock and may be applied 
either in an ascending or descending direction, as desired. 




Fig. 403. — Descending spica bandage of the buttocks. 




Fig. 404. — Ascending spica bandage of the thigh. 

Bandage of the Thigh.— To bandage the thigh alone a three-inch 
bandage is started by two turns just above the knee. It is carried 



536 



BANDAGING 



up the thigh by figure-of-eight or spiral reverse turns and ended by two 
circular turns about the upper part of the thigh. This bandage is very 
apt to slip and should be held in place by fixing its upper border with 
adhesive plaster. In ambulatory cases it is generally advisable to 
continue the bandage as a spica of the groin in order to give additional 
support. 




Fig. 405. — Figure-of-eight bandage of the knee or elbow, crossing on flexor surface. 





Fig. 406 Fig. 407 

Figs. 406 and 407. — Proper method of applying pressure bandage to the knee, show- 
ing figure-of-eight turns above and below the knee. No constricting turn directly 
around patella. 



Bandage of the Knee.— Bandage of the knee is exactly the same as the 
bandage of the elbow. It may be begun by a circular turn about the 
knee-cap and continued by figure-of-eight turns crossing behind the 
knee and extending in both directions, or it may begin either above or 
below the knee covered by converging turns. Care should always be 
taken not to cause constriction at the flexure of the knee. 



BANDAGES OF THE LOWER EXTREMITY 



537 



Bandage of the Leg and Foot.— This bandage is one of the most diffi- 
cult to apply. If applied correctly it will be comfortable and will 
give support to the leg. If apphed incorrectly it will soon become 




Fig. 408. — Method of starting a foot and ankle bandage. 

loosened and uncomfortable and may do harm. It is most used for 
applying pressure to varicose veins, varicose ulcer, and edema of the 




Fig. 409. — Foot and ankle bandage, partly finished. 



leg, and is usually combined with a bandage of the foot. A three-inch 
bandage is used. 

The bandage is started by two turns about the ankle and continued 



538 



BANDAGING 




Fig. 410. — Foot and ankle bandage, finished. 





Fig. 411. — Leg bandage, partly finished. 



Fig. 412. — Leg bandage, finished. 
Note application of bandage sup- 
porting area below malleoli. 



BANDAGES OF THE LOWER EXTREMITY 



539 



obliquely across the dorsum of the foot to the metatarsal region where 
a single turn is taken about the foot just above the web of the toes. 
The next turn crosses the dorsum of the foot obliquely and is carried 
around the back of the ankle, the lower margin running parallel to the 
sole of the foot. From here it is carried forward to cross the preceding 
turn on the dorsum of the foot then around the foot parallel to the 
preceding turn completing a spice of the foot and ankle. These turns 
are continued until the foot is covered and the bandage is fixed by two 
spiral turns about the ankle. The next turn extends obliquely to 
above the calf of the leg where a single circular turn is taken, and then 
obliquely downward to cross just above the narrowest part of the leg. 
It then passes around the leg and obliquely upward, overlapping the 
previous turn to behind the calf, where a reverse is made and the band- 
age is brought obliquely downward over the preceding oblique down- 
ward turn. These turns are continued, each figure-of-eight overlapping 
at the lower loop and reversing behind the calf and coinciding with the 
previous loop. The loops converge until the leg is covered. This 
bandage may continue upward to include a figure-of-eight of the knee 
and a bandage of the thigh if desired. If the heel is to be covered, the 
roller may be reversed behind the heel and carried down beneath the 
sole of the foot instead of on to the dorsal surface. Two or three of 
these reverses will cover the heel. Another method of covering the 
heel is to begin the bandage by a single turn about the heel. The 
second turn is carried across the sole of the foot beneath the heel and 
obliquely upward in front of the ankle and around the leg, then down- 
ward under the sole in front of the previous turn, continuing until the 
ankle and heel are covered. This is similar to the bandage of the knee. 




Fig. 413. — Recurrent bandage of the toes. 

Recurrent Bandage of the Toes.— A two-inch bandage is used. Two 
turns are taken about the foot and the bandage, reversed on itself at 
an angle of 90 degrees, is continued over the toes to the sole of the foot 



540 



BANDAGING 



and looped back at the level of the circular turn to return to the dorsum 
of the foot. The surgeon holds the recurrent loops with one hand while 
applying the bandage with the other. When the toes are covered, the 
ends of the loop are held in place by two or three circular turns. The 




I^ig. 414. — Bandage of foot showing return turns covering toes. 




Fig. 415.— Same as Fig. 414, finished. 



BANDAGES OF THE LOWER EXTREMITY 



541 



bandage may continue as a spiea of the foot and ankle or as a leg 
bandage. 

The toes may be covered individually in the same manner as the 
fingers, with a spiral or a circular bandage. Because the toes are so 
short, bandages slip easily and from a practical standpoint toes are 
seldom bandaged separately. When it is desired to apply a small 
dressing to a small injury, such as an abrasion or blister, it is better to 
hold the gauze in place with one or two narrow strips of adhesive 
plaster. 




Fig. 416. — Spica bandage of the foot, covering up and finishing recurrent bandage 

of the toes. 




Fig. 417. — Figure-of-eight bandage over recurrent end of the stump. 



Recurrent Bandage of a Stump.— An amputation stump is usually 
bandaged with a recurrent bandage in exactly the same manner as the 



542 



BANDAGING 



toes or the end of the finger. The width of the bandage used depends 
upon the size of the stump. If the bandage is not continued as an 
ascending bandage or spica it should be held in place with strips of 
adhesive plaster. 

BANDAGES OF THE TRUNK. 

Figure-of-eight Bandage of the Chest.— A three-inch bandage is 
started over the sternum, carried obliquely over the shoulder, behind 
the shoulder, under the axilla and back to the starting point ; then to 
the opposite shoulder, behind it, under the axilla, and back in front of 
the sternum. These turns may be repeated. It is used to hold 
dressings on the chest and to keep the shoulders forward. It is very 
liable to slip forward. 

A posterior figure-of-eight of the chest is exactly the same as the 
preceding, except that the bandages cross in the back and loop in front 
of the shoulders. It is used to keep the shoulders back and to hold 
dressings on the back. In either the anterior or posterior variety the 
turns may be made to overlap so that a considerable portion of the 
upper chest or back may be covered. 




Fig. 418. — Figure-of-eight bandage of the back. 

Spiral Bandage of the Chest.— This begins by circular turns about the 
lower part of the chest. The bandage then ascends spirally to the 
level of the axilla where it is fastened with pins, or it may be continued 
as a spica of one or both shoulders. Adhesive strips may be used to 
prevent slipping or two strips of bandage may be passed over the 
shoulder, suspender fashion, and pinned to the spiral turns in front and 
behind. This bandage may be used to hold dressings or to support 
broken ribs. 

Spiral Bandage of the Abdomen. —This is begun below the iliac crests 
and continued upward spirally. In patients with a large amount of 
abdominal fat or a tendency to a flaccid pendulous abdomen, this 



BANDAGES OF THE TRUNK 



543 



bandage will easily wrinkle and become loose. For such cases the 
many tailed abdominal binder is preferred. 





Fig. 419. — Spiral bandage of the 
abdomen. 



Fig. 420. — Many-tailed bandage ap- 
plied to the abdomen. 



Bandage of the Breast.— This bandage begins below the breast to be 
bandaged and passes obliquely upward across the chest to the opposite 




Fig. 421. — Supporting bandage of the breast. 

shoulder, then down across the back to the starting point. This turn 
is repeated in order to fix the bandage firmly and to support the breast. 
From here it is then carried around the chest in the transverse plane. 



544 



BANDAGING 



The turns alternate ; first, an oblique turn about the breast and shoulder 
and then a transverse turn about the chest, each turn overlapping the 
preceding so that the transverse turns progress upward and the oblique 
turns pass gradually toward the axilla. If simple support is all that 
is required, only the lower portion of the breast is covered; but if 
compression is desired, the bandage should be continued until the entire 
breast is covered. It is important that the oblique bandage be so 
directed that it runs upward from the breast to the shoulder. If it 
runs downward it will be less efficient and the application of the 
bandage will tend to drag the breast downward. 

Bandage of Both Breasts.— If both breasts are large and require 
support it is perhaps better to bandage the breasts separately. In 
most cases the bandage is started as for one breast with two oblique 
turns about the shoulder and breast, followed by a transverse turn 




Fig. 422. — Supporting bandage of both breasts. 



about the chest. The next turn passes obliquely across the back to 
the shoulder, over the shoulder and downward beneath the breast, 
and is followed by a second transverse turn about the body. The 
bandages cross in front over the sterum and behind in the midline of the 
back. As noted above, the best compression will be secured in the 
breast bandage from below upward. 

Many-tailed Bandage.— The simplest way to make this bandage is 
to tear a piece of muslin about eighteen inches wide and forty inches 
long so that it represents a central rectangle with six strips three inches 
wide at each end. These strips are used for an abdominal binder with 
the free ends brought together somewhat obliquely so as to cross. The 
points of crossing may be held in place by pins. For postoperative 
use this binder is usually made by sewing a number of strips of heavy 
muslin together so that they overlap about one-half around and the 
ends project as tails, This will weave much firmer than the torn 



THE TRIANGULAR BANDAGE 545 

bandage and each end is held in place by the next turn which crosses it. 
The final tails are pinned. 

In some cases the many-tailed bandage may be found useful in the 
application of splints or dressings to the extremities. It is frequently 
used to fix the arm and hold the dressing after operations upon the 
breast. 

Abdominal Binder.— Firm abdominal pressure may be secured by 
a muslin binder about twelve to eighteen inches wide which passes 
around the abdomen and is pinned in the median line in front. The 
binder after application will be found to be loose either above or 
below. A gusset is pinned either in the upper or lower margin so as 
to take up any fulness which occurs. 

Binder of the Breast.— In a strip of muslin twelve to eighteen inches 
wide and long enough to extend around the chest, armholes are cut 
so that a rough jacket is made opening in front. The jacket is 
pinned down the front fairly firmly and bands are pinned across 
the shoulders. The fulness at the sides of the chest and above and 
below the breast is taken up in folds and pinned with safety pins so 
that the binder fits snugly over the breasts. This binder after being 
applied may be tightened or loosened merely by adjusting the central 
row of pins. It is more comfortable than the bandage and more 
easily removed for inspection of the breast. 



THE TRIANGULAR BANDAGE. 

The triangular bandage, often called Esmarch's triangular bandage 
may be made from any suitable material such as linen, gauze, or 
unbleached muslin. A piece of cloth about a yard square is cut 
obliquely from corner to corner, the result being two triangular pieces 
with one long margin, the base, and two shorter margins, the sides. 
The corner opposite the base is called the apex or point, and the two 
corners at each end of the base are called the ends. The bandage may 
be made any desired size, but for practical purposes the base should be 
about forty inches long. 

The bandage is usually applied folded two or more times in its long 
diameter, forming a sort of cravat. It may be used to secure splints 
and to retain dressings, but is inferior to the roller bandage for the 
application of direct compression in the case of swelling or for the 
control of hemorrhage. It is used considerably as a first-aid bandage 
because it may be quickly and fairly satisfactorily applied as an 
emergency bandage by volunteer aids. For the trained worker the 
roller bandage will be found more satisfactory except in very excep- 
tional circumstances. It is in many cases difficult or impossible to 
apply the triangular bandage so as to secure a firm, neat bandage. 
The surgeon seldom uses the triangular bandage except for the broad 
sling of the arm, in which case it is superior to the roller bandage. 
35 



546 



BANDAGING 



The bandage may be used on any part of the body. The general 
method of application may be indicated by the following bandages 
which are illustrative of the manner in which it may be used. 




Fig. 423. — Emergency triangular bandage, used by Abratzie Polar Expedition, showing 

methods of applying. 




Fig. 424. — Correct method of applying sling. Note the support to the hand. 

Bandage of the Scalp.— Lay the middle of the bandage on the head 
so that the base lies crosswise over the forehead, the apex passing 
backward and hanging down over the nape of the neck. Carry the 
two ends backward above the ears and cross them behind the head 
over the apex of the bandage, and finally pin or tie the ends over the 
forehead. The apex or point is brought forward and pinned on top 
of the head. 

Cravat of the Eye.— The bandage is folded into a narrow strip about 
two inches wide. The center of the cravat is placed over the eye and 



THE TRIANGULAR BANDAGE 547 

the ends are carried obliquely around the head and tied behind; or if 
the ends are long enough they may be crossed behind and brought 
forward and tied in front. 

Dressings may be retained in a similar manner on the forehead, 
beneath the chin, on the ear, and in many other locations. 

Bandages of the Chest.— Place the middle of the bandage on the chest 
with the apex over one shoulder. Carry the ends around the chest 
and tie them at the back. Carry the apex over the shoulder and pin 
behind. 

Bandage of the Back.— This is similar to the bandage of the chest 
except that it is started at the back and pinned or tied in front. 

Bandage of the Axilla. —The bandage is folded and a point near the 
center is placed on the dressing in the axilla. The anterior end, which 
should be the shorter, is carried in front of the shoulder and over the 
shoulder to the back. The posterior end curves up over the same 
shoulder, runs obliquely across the chest to the opposite axilla, extends 
beneath the axilla and is fastened to the other end of the bandage 
behind the back. 

Bandage of the Hip.— Fold a bandage narrow and tie it around the 
body for a waistband. Lay the center of a second bandage on the 
dressing with the point upward. Pass the ends around the upper part 
of the thigh, cross them, and tie them close to the starting point. Next, 
pass the point of the bandage up beneath the belt, draw it snugly and 
fasten with one or more safety pins. 

Bandage of the Arm.— The bandage is folded wide and the center 
placed over the dressing. The ends are carried once or twice around 
the joint and tied or pinned. 

Bandage of the Foot.— With the bandage spread out on the floor, 
place the sole of the foot at its center, the toes pointing toward the apex. 
Draw the point upward over the dorsum of the foot, carry the two ends 
forward to cross over the dorsum, then completely around the ankle to 
cross again over the instep, and finally to tie beneath the sole of the 
foot. 

Broad Sling of the Arm. —Place one end of a triangular bandage over 
the shoulder of the sound side and draw the end around the neck, so 
that it is visible over the shoulder on the opposite side. The apex 
of the bandage is placed behind the elbow on the injured side and the 
other end of the bandage hangs down in front of the patient. Next, 
bend the arm carefully and place it across the chest about the middle 
of the cloth, and carry the lower end up in front of the injured forearm 
over the shoulder on the same side and tie it with the other end at the 
nape of the neck. The apex is then drawn forward in front of the 
elbow and fixed with a pin. 

The Handkerchief Bandage.— A large handkerchief may be folded 
obliquely from point to point and used as a triangular bandage. The 
open handkerchief is sometimes used for a bandage of the capitellum 
by placing the handkerchief over the top of the head with the points 



548 



BANDAGING 



hanging down in front and behind and on each side. A circular or 
folded bandage is now placed around the occipito-frontal diameter of the 
head and the corners of the handkerchief are turned back and pinned 
on top of the head. The hand, foot, or an amputation stump, may be 
bandaged in the same manner. 




Fig. 425. — Handkerchief bandage of the scalp. 



SPECIAL BANDAGES. 

The T -bandage.— This bandage consists of a waistband about three 
inches wide, in the center of which is sewn a similar strip about thirty 
inches long. It is used to hold dressings on the perineum, anus, or 
vulva. The waistband is tied or pinned with the cross-piece attached 
in the midline behind. The end is brought forward over the dressing 
and fastened to the waistband in front. A similar bandage may be 
used to hold dressings on the back or chest, the horizontal strip passing 
around the chest and the vertical strip over the shoulder. 

The Two-tailed T -bandage.— This is used to hold dressings in the 
perineal region or about the anus or groin, and is generally used in 
place of the ordinary T-bandage in the male. The waistband is the 
same as described above but the vertical strip is divided longitudinally 
in two strips which pass forward to each side of the scrotum and are 
fastened to the belt about four inches apart. 

Suspensory Bandage of the Scrotum.— This is similar to the T-bandage 
except that the vertical piece is about six inches wide in front. The 
bandage is applied in such a way as to hold the scrotum and penis up 
against the abdomen, the end being pinned broadly to the belt. A 
hole may be cut for the penis if desired. 

Hammock Suspensory.— A simple belt is applied and a broad piece 
of muslin or gauze about sixteen inches long and eight inches wide is 
pinned to the belt at the anterior superior spines in such a manner 
as to hang like an apron, the upper edge being behind the scrotum. 
The lower edge is now brought upward and pinned to the belt, making 
a hammock-like sling for the penis and scrotum, 



SPECIAL BANDAGES 



549 



Four-tailed Bandage.— The use of the four-tailed bandage about the 
head has already been described. A slightly modified four-tailed 
dressing is frequently used for an eye bandage. A small pad of gauze 
or muslin about two inches wide and three or four inches long has a 




Fig. 426. — Simple form of two-tailed T-bandage. 




Fig. 427.- 



-Siinple supporting bandage of the scrotum, T-bandage shown in Fig. 426. 

in use. 



strip of narrow tape attached to each corner. The pad is placed over 
the eye and the tapes are tied behind. In dressings about the head, 
where any bandage is sometimes considered objectionable because it 
attracts attention, small dressings may be held in place by a four- 
tailed bandage, made of black silk and black tape as described above. 



CHAPTER XXI. 
LOCAL ANESTHESIA. 

COCAIN. 

The anesthetic properties of cocain were first brought to the attention 
of the medical profession during the latter part of the nineteenth cen- 
tury. In 1887 Wolfler collected a large number of reports of operations 
performed under cocain anesthesia and for many years after this date 
local anesthesia and cocain anesthesia were practically synonymous. 

The symptomatology and the toxicology of the administration of 
cocain are now well recognized and it should be the aim of the surgeon, 
bearing the toxic effects constantly in mind, to use this powerful drug 
in such a manner as to secure the maximum local effects with the 
minimum general toxic effects. We have practically discarded cocain 
in our practice whenever it is possible to secure novocain or one of the 
other less dangerous anesthetics. 

It is impossible to name any definite, safe dose of cocain. The 
maximum dose as given by various authorities varies between one- 
third of a grain and two grains. It must be remembered, however, 
that a great deal depends upon the rapidity with which the drug is 
absorbed, which, in turn, depends upon the strength of the solution 
used and the freeness of the circulation through the part injected. 
Injected into the blood stream, a small fraction of a grain of cocain 
may cause death; while comparatively large doses may be injected if 
rapid absorption is prevented. In general the toxic effects are more 
marked in injections made about the head and face than in injections 
about the extremities. 

In order to prevent rapid absorption there are three rules which 
should be faithfully adhered to: (1) The injection should be made 
with a moving needle to avoid injecting a considerable quantity into 
a vein; (2) strong solutions should never be used; 0.5 of 1 per cent 
solutions are as strong as are ordinarily required; (3) in the use of 
cocain any method which tends to hinder absorption allows for an 
increased injection of cocain with less danger of poisoning (ligature, 
adrenalin, etc.). 

Bearing these rules in mind it is safe to say that, except under very 
exceptional circumstances, up to a grain of cocain can be injected 
without danger of toxic symptoms. In the case of idiosyncrasies and 
in operations about the head, the dose should be much smaller. 

In the early use of cocain 5 and 10 per cent solutions were frequently 



NOVOCAIN 551 

used for local anesthesia of the mucous membranes. Several reports 
of death following the use of not more than 2 or 3 grains used in this 
manner lead to the abandonment of these strong solutions. The 
urethra and bladder seem to be especially susceptible to the action 
of cocain, even in dilute solutions. 

In consideration of certain idiosyncrasies, it follows that definite 
rules cannot be established for the use of cocain. Instances have been 
reported in which 3 or 4 grains have been injected without ill effect; 
but cases of severe toxic symptoms from comparatively small amounts 
are so common that injections containing 0.5 of 1 grain or more 
should be used with great care and in very dilute solutions. 

Treatment of Cocain Poisoning.— There is no known antidote for 
cocain. The patient should be placed in the horizontal position and 
remedies applied to diminish anemia of the brain. Amyl nitrite 
inhalations have been advised. If convulsions occur they may be 
controlled by ether and chloroform inhalations. Respiratory failure 
may be prevented by the use of stimulation hypodermically and by 
mouth. Artificial respiration should be resorted to in case of threat- 
ened respiratory paralysis. In poisoning after an injection into the 
arm or leg, a tourniquet should always be applied above the injection 
in order to diminish absorption. 



NOVOCAIN. 

This is a crystalline synthetic compound which is less toxic than 
cocain and yet has at the same time very similar and almost as great, 
local anesthetic effects. In rabbits the fatal dose is about four times 
that of cocain. Novocain has marked anesthetic properties without 
local irritation, but its anesthetic action does not persist as long as 
cocain. It penetrates mucous membrane much less thoroughly than 
cocain and consequently is of less value when applied directly to the 
mucous membrane. 

Just as in the use of cocain it is impossible to state definitely the safe 
dose of novocain. The size of the dose safely borne depends upon the 
strength of the solution injected and the rapidity of absorption. 
However, it is considerably less toxic than cocain, the figures given 
varying from one-seventh to one-third. Using 0.5 per cent solutions 
combined with suprarenin it is ordinarily considered safe to inject 
from 50 to 100 cc, that is, from 3 to 1\ grains or thereabouts. Even 
in this solution care should be exercised in operations about the head 
and neck. Cases are frequently seen where 200 cc or more of a 0.5 
per cent solution (about 15 grains) have been given in the course of an 
operation without ill effects, but in such cases a great deal escapes 
through the incision and the absorption of the remainder is greatly 
delayed by the use of adrenalin, so that it is highly probable that not 
more than 3 or 4 grains are absorbed into the general circulation. 



552 LOCAL ANESTHESIA 

Novocain Poisoning.— The toxic symptoms referable to the use of 
novocain are sensory paralysis extending to the face and head, numb- 
ness, dizziness and weakness. The treatment is the same as in cocain 
poisoning. 

ADRENALIN IN LOCAL ANESTHESIA. 

As has been noted, the local effects of cocain and novocain may be 
increased and occurrence of toxic symptoms may be delayed or entirely 
prevented by the use of any method of delaying absorption. Absorp- 
tion may be prevented mechanically by constriction of the circulation 
of the part by bands or ligatures, by the application of cold which 
constricts the vessels, or by the injection of suprarenin (adrenalin) 
in dilute solution which causes a similar constriction of the smaller 
arterioles. In order to avoid general disturbance and too active local 
constriction of the vessels from the use of adrenalin, it is advisable to 
limit the injection to 0.5 cc or less of the 1 to 1000 solution of adren- 
alin, which should preferably be added to not less than 100 cc of the 
novocain solution. If stronger adrenalin is used the constriction may 
be so great that smaller arteries are rendered entirely blood-free and are 
consequently overlooked when measures for hemostasis are applied. 
Later after the immediate effect of the adrenalin wears off and the 
arteries relax secondary hemorrhage may occur. In addition to this 
danger, the use of even weak adrenalin solution in skin-flaps and in 
other locations where the circulation is poor may result in sufficient 
constriction of the vessels to interfere seriously with the vitality of 
the tissues occasionally leading to gangrene of the skin. 

Suprarenin has been manufactured synthetically and this product 
has been found to have the same effect as the glandular extract. The 
synthetic compound has been found more stable and its action less 
variable than the extract, and for this reason it has come into wide use 
in the field of local anesthesia. In using very strong solutions of 
novocain (the use of which is seldom justified) the suprarenin may be 
used in stronger solution than 0.5 per cent 

The following rule is given by Braun 1 for the use of suprarenin in 
combination with novocain: 

1 cc suprarenin solution (1 to 1000) to be added to: 

200 cc of 0.5 per cent novocain solution. 

100 cc of 1 per cent novocain solution. 

50 cc of 2 per cent solution. 

25 cc of 4 per cent novocain solution. 

From the above it is a simple matter to calculate the amount required 
for smaller quantities of the various solutions. 

1 Local Anesthesia, English translation by Shields; Lea & Febiger, Philadelphia, 1914. 



METHODS OF APPLICATION OF LOCAL ANESTHESIA 553 

METHODS OF APPLICATION OF LOCAL ANESTHESIA. 1 

The simplest method of applying local anesthesia is the direct appli- 
cation of the anesthetic solution to the surface to be anesthetized. 
This method is suitable only in anesthetizing mucous membranes and 
open wounds. It is impossible to obtain any effect by the use of 
ordinary solutions upon the unbroken skin. In the mouth and throat 
small quantities of fairly strong solution of novocain may be used, 2 
to 5 per cent or even stronger, care being taken not to permit the excess 
to be swallowed. In the nose these solutions must be used with great 
care, especially if the nose is packed with gauze soaked in the solution 
used. In the eye, two or three drops of 2 per cent solution are strong 
enough to thoroughly anesthetize the conjunctiva. In the bladder and 
urethra very dilute solutions must always be used. Death has been 
reported after an injection of 2 per cent cocain solution into the bladder 
even when the bladder was immediately emptied. If the urethra or 
bladder is to be anesthetized a solution not stronger than 0.5 per cent 
should be used. A similar solution may be used in joint-cavities and 
the interior of serous sacs such as a hydrocele sac, but such injections 
are not free from danger and should be avoided whenever possible. 

Surgical operations are usually performed under anesthesia obtained 
by either infiltration or conduction. Infiltration anesthesia consists 
of direct injection into the tissues to be operated upon, the aim being to 
paralyze the nerve endings. Conduction anesthesia consists of the 
blocking of the nerve impulses at a point central to the field of operation 
by injections into and around the nerve, the result being anesthesia 
over the area supplied by the nerve. These methods may conveniently 
be discussed together because, as a rule, both methods are used con- 
jointly to secure local anesthesia. In general, it is advantageous to 
make the greatest possible use of conduction anesthesia in every case, 
because it allows for the maximum area of anesthesia with a minimum 
amount of anesthetic. Practically, it is ordinarily very difficult to 
overcome the technical difficulties in the use of conduction anesthesia 
alone. 

In the practical application of conduction anesthesia, advantage is 
taken of the fact that when a solution of novocain is injected in the 
region of the nerve, the nerve will be blocked and the region supplied 
rendered anesthetic. For this reason, care is always taken to inject 
several cc of the local anesthetic in the region of the larger nerves 
supplying the operative field. In some cases, as for instance, the ulnar 
nerve at the elbow, the injection may be made at a considerable 
distance; in others, the nerve may be blocked close to the field of opera- 
tion. In addition, the entire area through which the nerve fibers run 
may be infiltrated so that all the smaller nerve filaments will be blocked. 
It is rarely considered necessary to inject the skin along the line of 

1 In the following pages novacain is the anesthetic referred to unless the contrary 
is definitely stated. 



554 



LOCAL ANESTHESIA 



incision, as was previously advised, for the preliminary injections 
should, if properly performed, render the skin anesthetic, together 
with the rest of the field of operation. The exception to this rule is 
seen in those cases where only a small skin incision is required, in which 
event anesthesia may be secured by a series of wheals, as described 
below. 

The selection of a syringe which may be easily manipulated with 
one hand is important. It is a mistake to attempt anesthesia with 
the ordinary hypodermic syringe. A 5 cc syringe is usually found 
satisfactory, but a 10 cc syringe is even better if it is available. For 
routine work a small gauge needle about 5 cm. in length will fulfil all 
requirements. Short needles should not be used, because when deep 
injections are necessary the needles must be plunged into the tissue 
for the entire length and if broken in this position they are very likely 
to be lost. 1 




Fig. 428. — Formation of a skin wheal. (Braun.) 

In very tough tissue such as the palms of the hands, the soles of the 
feet, and the periosteum, it may require considerable pressure to inject 
the solutions into the tissues. In such cases a syringe having a small 
barrel will secure greater pressure than a syringe of larger caliber. 
The all-metal syringe used by dentists is the best for work of this sort. 

At the point of injection the skin is made anesthetic by the injection 
of a few drops into the skin, forming a wheal. 



1 It may be noted that needles are likely to break where the needle joins the hub and, 
for this reason, it is a wise precaution never to plunge the entire shank of the needle into 
the tissues. 



TECHNIC OF LOCAL ANESTHESIA 



555 



TECHNIC OF LOCAL ANESTHESIA. 

The wheal, as mentioned above, is the simplest form of skin anes- 
thesia. For a straight incision a number of these wheals may be made 
in a line and the incision made along this line. However, it is now 
considered better to inject the subcutaneous tissue beneath the line of 
incision, the skin being rendered anesthetic by means of conduction 
anesthesia. In this manner, the skin, the subcutaneous tissues, and 
the nerve filaments passing through this area are all anesthetized. In 
the case of an arm or a leg the entire part may be encircled so that all 
the subcutaneous nerves are affected. We have frequently seen 
surgeons, in anesthetizing a finger for incision, start their injections 
at the tip and gradually proceed toward the base, thus forcing each 
injection into a fresh, sensitive field. It is important that the first 
injection be made proximally, so that the following injections will be 
made in tissue already partially anesthetized. In addition, if a long 
needle is used, a large area of the subcutaneous tissue may be covered 
from a single point of puncture. 




Fig. 429. — Showing cross-section of forearm. (Braun.) 

In the case of a large operative field, the infiltration is made to 
surround the entire area of operation. Pedunculated tumors may be 
excised after subcutaneous infiltration at the base, or a finger may 
be incised after a circular infiltration of the tissues surrounding the 
proximal phalanx. This method of subcutaneous "blocking" is only 
successful in cases where the entire nerve supply passes through the 
subcutaneous tissues. If the nerves come from directly beneath the 
operative field, it is necessary to inject directly into the deeper parts 
in order to secure complete anesthetization. The injection usually 
begins close to the bone and progresses outward injecting the various 
layers in turn. The periosteum itself may be anesthetized by the 
infiltration of the tissues surrounding it, because its nerve supply 
passes inward from the surrounding tissues and not outward from the 
bone. If the periosteum is well anesthetized there will be no sensation 
in the bone. 

In order to prevent the injection of a considerable quantity of 



556 LOCAL ANESTHESIA 

solution into an artery or vein the point of the needle should be kept 
moving slowly during injection. 

When nerve trunks have been exposed during operation they may be 
anesthetized by the direct injection of a small amount of 0.5 per cent 
novocain-suprarenin solution. 

Local anesthesia is recommended by Quenu in the treatment of 
simple fractures. The anesthesia is obtained by the injection of 0.5 
per cent novocain solution about the fractured ends of the bones and 
in suitable cases into the nerves supplying sensation to the part. The 
results are said to be most striking, the pain being relieved within a 
few minutes. Muscular relaxation is said to be nearly as complete as 
under general anesthesia. The main objection to the direct injections 
of solution about the fractured ends of the bone is the danger of infec- 
tion. If this method is used, most careful attention should be given 
to the aseptic preparation of the solution and to the technic of the 
injection. In a similar manner injections may be made directly into 
the joints for the reduction of dislocations and joint fractures. We 
have treated too few cases by this method to form definite conclusions 
as to its usefulness, but in our opinion nitrous oxide is far safer and 
gives better relaxation of the muscular tone, thus promoting the ease 
of reduction. 

TECHNIC OF OPERATIONS. 

In the following pages certain operations will be given in detail in 
order to indicate the general plan of procedure in different locations. 
Unless otherwise stated 0.5 per cent novocain-suprarenin is used. 

Scalp. —The nerves of the scalp pass upward from the forehead, and 
the temporal and occipital regions. As the nerves in this region are 
all subcutaneous, anesthesia can be obtained by conduction anesthesia, 
that is, by interrupting the nerves. Complete anesthesia can thus be 
obtained of the scalp, fascia, periosteum, and bone. In operations 
upon the bone, subperiosteal injections are unnecessary. The accom- 
panying illustration shows the method of injecting the scalp for 
the incision of a large sebaceous cyst. 

The injection is made at two points and the subcutaneous infiltration 
is carried out along the dotted lines. It is rarely necessary to inject 
more than 20 cc of 0.5 per cent novocain-suprarenin solution in such 
cases. 

In large operations a rubber band may be placed about the head 
just above the ears firmly enough to cause hemostasis. This allows of 
anesthetization with less solution and gives a longer period of anes- 
thesia. 

Face.— In operations upon the face the branches of the trigeminus 
may. be blocked as they exit from the skull. The technic of these deep 
injections is very difficult to master and is usually unnecessary except 
in major operations. For ordinary purposes cir cumin jection is all 
that is required. However, there are certain nerves, such as the 



TECH NIC OF OPERATIONS 



557 



supraorbital and the infraorbital, which may be easily located with the 
finger or the point of the needle just as they leave the supraorbital 




Fig. 430. — Method of obtaining ' anesthesia for operation on a large sebaceous cyst. 

(Braun.) 

notch and the infraorbital canal. They should be blocked at these 
points for operations occurring in the region which they supply. The 




Fig. 431. — Method of circuminjection for operation on the nose. (Braun.) 



inferior dental nerve may be reached and blocked just before it enters 
the bony canal in the lower jaw. 



558 



LOCAL ANESTHESIA 



In Fig. 431 anesthesia of the nose is shown, the injection being 
made about the nose from three points of injection. Usually from 
20 to 30 cc of solution are required. 

Neck.— Most of the sensory nerve supply of the neck comes from the 
cervical nerves. Figure 432 shows the lines of injections for operation 
on one or both sides of the neck. 

The subcutaneous and subfascial planes are infiltrated from the 
points and long the lines indicated. Tuberculous glands have been 
removed, thyroidectomy has been performed, and many operations, 
both major and minor, may be painlessly carried out by this method. 




Fig. 432. — Circuminjection for operations upon the neck. (Braun.) 



Local Anesthesia for Thoracotomy.— Two superficial injections are 
made three inches apart along an intercostal space. The deep injection 
is made at the point nearest the spine, the needle being directed 
obliquely toward the upper rib. When the needle touches the rib an in- 
jection is made between the rib and the skin and then, using the rib as a 
guide, between the layers of the intercostal muscles. It requires a little 
practice to be sure that the needle is between the intercostal muscles 
and not in the pleural sac, but if the point of the needle is made to 
follow the course of the rib this should be easily accomplished. The 
injection should also include the subcutaneous tissues over the rib. 

When it is desired to resect a portion of a rib, the injection should be 
made at four points, two above and two below the rib to be resected, 
as shown in the diagram, Fig. 433. 

At the four points of puncture novocain is injected directly into the 



TECH NIC OF OPERATIONS 



559 



intercostal muscles. The tissues superficial to the ribs are then 
injected in the direction of the arrows. If this is carefully carried out, 
using about 50 to 70 cc of 0.5 per cent novocain-suprarenin solution, 




Fig. 433. — Diagrammatic representation of the method of injection in the operation for 
resection of a rib. The dark area is the portion to be resected. (Braun.) 

complete anesthesia of the periosteum and bone will be obtained. The 
parietal pleura will be found to be insensitive if the intercostal spaces 
have been properly infiltrated. 




Fig. 434. — Showing points of injection and area of anesthesia after blocking of the inter- 
costal nerves. (Braun.) 

Blocking of the Intercostal Nerves.— The intercostal nerves may be 
blocked centrally if desired. The best location is at a point about 
5 or 6 cm. from the midline. The skin is first infiltrated at the point 



560 



LOCAL ANESTHESIA 



of injection and then the needle is pushed through the muscles until 
the rib is reached. A little solution is injected about the rib and then 
the point of the needle is passed along the surface of the rib until it is 
felt to slip past the lower border. It is then passed a short distance 
(about 0.5 cm.) into the intercostal space and about 5 cc of the solution 
is injected at this point. If more than one nerve is to be blocked it is 
advisable to leave this needle in place as a guide while a second needle 
is introduced and the adjoining intercostal space is injected in the same 
manner as above. This process can be continued until several inter- 
costal nerves have been blocked. 

Operations upon the Abdomen.— In operations for subcutaneous 
tumors or other local affections of the abdominal wall a combination 
of circuminjection and nerve blocking gives the best results. Near the 
midline, infiltration anesthesia alone gives better results than attempts 
at nerve blocking. 




Fig. 435. — Anesthesia obtained by nerve blocking. (Braun.) 



Operations upon the Penis and Scrotum.— In order to obtain complete 
anesthesia of the penis and scrotum a circular injection should be made 
about the base of the penis and the attachment of the scrotum. Injec- 
tion is started from a point where the spermatic cord crosses the pubic 
bone, the needle being passed inward until the bone is reached, and a 
fan-shaped infiltration is made perpendicular to the bone from the 
symphysis to a point external to the spermatic cord. Reclus has 
advised the injection of the spermatic cord while it is lifted and held 
between the fingers, but if the fan-shaped injection is thoroughly 



TECH NIC OF OPERATIONS 



561 



carried out, this will be unnecessary. In any event it is well to inject 
a few cc into the inguinal canal to block the nerves accompanying the 
cord. A second point of injection is made where the fold of the scrotum 
joins the thigh and from this point subcutaneous injections are made 
about the base of the scrotum. If the operation is limited to one side 
the anesthesia may be limited to the same side, but if a more extensive 
operation is contemplated both pubic regions must be infiltrated and 
the entire scrotum must be circuminjected. 

Operations on the Penis.— For simple operations upon the prepuce, 
local infiltration is all that is required. Circumcision can be accom- 
plished by injection of the mucous membrane and skin along the line 




Fig. 436. — Showing the points for circuminjection of the entire penis and scrotum. 

(Braun.) 

of incision, but it is performed more easily under conduction anesthesia, 
obtained by circuminjection about the base of the penis. A puncture 
is made at the point where the spermatic cord crosses the horizontal 
ramus of the pubis. The surrounding tissues are injected with 0.5 
per cent novocain solution. This infiltration is carried anteriorly 
to the midline and downward and inward to the scrotum. The needle 
is then passed deep to the base of the corpus cavernosum and the 
surrounding tissues are injected along the corpus cavernosum to its 
junction with its mate of the opposite side. This process is repeated 
on the opposite side. 

Local Anesthesia of the Anus.— Local anesthesia in the region of the 
anus may be secured by local infiltration at the point of operation, or 
36 



562 



LOCAL ANESTHESIA 



by complete anesthetization of the entire anal region through cir cum- 
in jection about the lower part of the rectum. Rectal circumin jection 
is performed as follows: With one finger introduced into the rectum 
as a guide, from 60 to 100 cc of solution are injected into the tissues 
about the rectum at a depth of about 6 to 8 cm., care being taken not to 
pass the needle into the rectum. The points of injection are arranged 
symmetrically about 4 cm. from the anal margin, and the injection is 
made in a fan-shaped direction so as to surround completely the lower 
segment of the rectum. By this procedure hemorrhoids may be 
excised, fistulas may be excised or curretted, and in some cases forcible 
dilatation of the sphincter can be accomplished. 




Fig. 437. — Circuminjection of the penis showing the points of injection. (Braun.) 



Operations on the Fingers. — Fingers may be anesthetized by the 
injection of a suitable solution about their base. Two points of 
entrance are chosen on the dorsal and lateral surfaces, because at these 
points the skin is less sensitive than on the palm. The cross-section 
(Fig. 438), is shown diagrammatically, the points of entrance being 
shown by large dots (1 and 2), the nerves being shown by smaller 
dots. The direction of the injections is indicated by arrows. 

The duration of anesthesia may be conveniently increased by the 
use of a ligature placed about the finger. Usually about 5 cc of solu- 
tion are required. Because the arteries of the fingers are end arteries, 
Braun advises the use of novocain solution without the addition of 
adrenalin, in order to avoid the evil effects of prolonged constriction 
of the vessels. 

In order to anesthetize one finger and the adjoining portion of the 
hand, the injections are made in the interdigital fold on each side of the 



TECH NIC OF OPERATIONS 



563 



finger to be operated upon. The needle is directed upward between the 
metacarpal bones toward a point on the dorsum of the hand from 2 to 
5 cm. above the metacarpophalangeal joint. Injections are then 
made on the palmar aspect toward a corresponding point anteriorly. 




Fig. 438. — Schematic cross-section of the base of a finger showing the direction of 
injection, a, flexor tendon; b, bone; c, extensor tendon. 1 and 2 points of injection. 
(Braun.) 

Disarticulation of the metacarpophalangeal joint and operations 
upon the distal end of the metacarpal bones are performed, according 
to Braun, as follows: Four points of entrance must be marked on the 




Fig. 439. — Point of entrance for operations upon a metacarpal bone of the thumb and 

one finger. (Braun.) 

hand, two of them in the interdigital folds (1 and 2) and two on the back 
of the hand over the interosseous spaces to each side of the metacarpal 
bone (3 and 4). From these latter points the needle is passed directly 



564 



LOCAL ANESTHESIA 



forward until the point can be felt beneath the skin of the palm, injec- 
tions being made during the passage of the needle. For each of these 
injections about 5 cc of 0.5 per cent novocain-suprarenin will be 
required. From the same point a small amount of solution is injected 
over the dorsum of the bone. The injection should be performed in 
such a maimer that the entire bone is circuminjected at this point. 
From the points 1 and 2 the subcutaneous tissue is infiltrated toward 
the points 3 and 4 and the point b on the palm. 

Altogether between 30 and 40 cc of solution are used. The anes- 
thesia is complete when the tip of the finger becomes anesthetic, the 
time required for this being about five minutes. It may be mentioned 
in passing that in all operations where novocain is used it is necessary 
to wait several minutes for anesthesia to become complete. Many 
surgeons have discarded local anesthesia as unsatisfactory because 
they have operated immediately after the injection and have been 
surprised and disappointed that the patient experienced severe pain. 




Fig. 440. — Direction of injection on palmar surface for operation on metacarpal bones. 

(Braun.) 

The same method, with slight modifications in the case of the index 
and little fingers, may be used for operations upon the distal portion 
of the metacarpal bones of the other fingers. The necessary modifica- 
tions become at once apparent from the study of the figure. 

In slight operations upon the palmar or dorsal aspects of the fingers, 
we have found that a small, semicircular injection proximal to the lesion 
gives a satisfactory anesthesia. 

Operations upon the Thumb.— Complete anesthesia of the thumb and 
distal half of the first metacarpal bone may be obtained by injections 
at the points 5, 6 and 7 in Fig. 439. The injection is begun 
at point 6, and the tissues are infiltrated until the point of the needle 
can be felt beneath the palm at a. From 5 and 7 the tissues are. 



TECH NIC OF OPERATIONS 565 

infiltrated on the palm toward a, and on the dorsum of the hand 
toward the point 6. About 50 cc of 0.5 per cent soluton are required. 
The special advantage claimed for this method is that the entire 
thenar eminence is anesthetized without the necessity of puncturing 
the sensitive palmar skin. By this procedure the thumb may be 
amputated painlessly at the metacarpophalangeal joint, either with 
or without removal of the head of the metacarpal bone. The same 
method may be used in the reduction of a dislocation at this joint 
either by the closed or open operation. 

In spite of the fact that it has been frequently demonstrated that 
if the injections are carefully made, amputations and other bone 
operations may be rendered absolutely painless, many surgeons still 
refuse to use local anesthesia for operations of this sort, claiming that 
they are unable to obtain complete anesthesia of the bone. It should 
be emphasized again that the preliminary injection should be carefully 
made to include all nerve fibers, and that plenty of time should be 
allowed for it to take effect. It is very difficult to secure any appreci- 
able effect from direct injections after the operation has been begun. 

Operations upon the Hand. — Small operations upon the hand are best 
performed by the use of local infiltration anesthesia circuminjected 
about the lesion. For larger operations, the blocking of the nerve- 
trunks is found to be the most useful method. Four nerves must be 
blocked; the ulnar, the median, the radial, and the posterior inter- 
osseous. In some cases, depending on the location of the lesion, it is 
not necessary to block all of these nerves. The ulnar nerve may be 
most easily blocked at the inner condyle of the humerus where it can 
be distinctly felt. The point of the needle should be introduced into 
or near the nerve and about 1 cc of 1 per cent novocain-suprarenin 
solution injected. The median nerve is reached at the wrist, where it 
lies just beneath the tendon of the palmaris longus. If 4 or 5 cc of 
1 per cent solution are injected in the vicinity of this nerve, anesthesia 
results. In searching for the nerve with the point of the needle, the 
patient should be asked to indicate when he has sensations of tingling 
or pain in the area of median distribution. These or similar sensations 
indicate that the point of the needle is in contact with the nerve. The 
branches of the radial nerve are blocked by subcutaneous injections into 
the tissue on the radial side of the wrist, and the branches of the 
interosseous by deep injections into the muscles attached to the 
posterior surface of the interosseous membrane. In addition to this 
it is often necessary to infiltrate the subcutaneous tissues about the 
wrist in order to interrupt the end filaments of the branches given off 
higher in the arm from the ulnar and median nerves. 

Operations on the Foot.— The toes can be made anesthetic in the same 
manner as the fingers. The procedure for the great toe is slightly 
different than it is for the thumb, but the principle is the same. The 
injections are made at points similar to those used in operation on the 
index finger. 



566 



LOCAL ANESTHESIA 



For disarticulation of the great toe, or for the operation for hallux 
valgus, the injections are made at three points. The first is at the 
junction of the dorsal and median surfaces of the foot, about 6 cm. 
behind the metatarsophalangeal articulation. The second is on the 
dorsal surface of the foot over the interosseous space at the level of the 
first injection. The third point is in the fold between the first and 
second toes. From the first point the needle is passed toward the 
plantar surface of the foot keeping close to the metatarsal bone and 
injection about 3 cc of solution. The needle is then partially with- 
drawn and passed beneath the skin across the dorsum of the metatarsal 
bone to the second point, injecting about 2 cc. 




Fig. 441. — Injection for hallux valgus operations. (Braun.) ■ 

The injection is now made from point 2, (Fig. 441), the needle being 
passed directly through the interosseous space until the point can be felt 
beneath the skin of the plantar surface of the foot. About 5 cc are 
injected close to the bone and into the interosseous space. An injec- 
tion is now made from point 3 along the sole of the feet corresponding 
to the line 3-2. This third injection is not always required, for if the 
second injection be completed by injecting in a fan-shaped manner 
the entire interosseous space from point 2 to point 3, complete anes- 
thesia of the bone and soft parts in the region of the joint will result. 
While Braun advises the use of 40 to 50 cc of a 0.5 per cent novocain- 
suprarenin solution, we have found that more than 25 or 30 cc are very 
rarely required. We have operated upon numerous cases of hallux 
valgus by this method and have never seen any pain, even during 
operations lasting as long as thirty minutes. 

Complete Anesthesia of the Foot.— The entire foot may be made 
insensitive to pain by blocking all the nerves as they pass across the 
ankle-joint. Five nerves must be blocked; the posterior tibial, the 
anterior tibial, the internal saphenous, the external saphenous, and the 
musculocutaneous nerves. 



SACRAL ANESTHESIA 567 

The posterior tibial nerve may be blocked by a deep injection of 
1 per cent novocain-suprarenin into or around the nerve where it lies 
behind the internal malleolus between the tibial artery and the tendon 
of the flexor longus hallucis. It is advisable to make the injection 
high up so as to inject the nerve before the plantar cutaneous branch 
is given off. The anterior tibial should be blocked where it passes 
under the anterior annular ligament, lying to the outer side of the 
anterior tibial artery. The internal cutaneous nerve is blocked by a 
subcutaneous injection of 0.5 per cent novocain-suprarenin about the 
internal malleolus injected in a transverse area extending nearly half- 
way around the leg. In the same manner a strip is infiltrated across 
the external malleolus, blocking the external saphenous and the 
musculocutaneous nerves. By this method the foot may be anesthe- 
tized sufficiently to perform operations on the tarsus or amputations 
in the tarsal or metatarsal regions. 

SACRAL ANESTHESIA. 

Since Parker Syms first called our attention to the local anesthesia 
of the sacral and coccygeal nerves, we have used it in a number of 
cases with complete success and satisfaction. We find the technic 
simple, safe and complete, and we feel that it should be more generally 
used. 

In sacral anesthesia advantage is taken of the fact that the dura 
ends at about the upper border of the sacrum, thus leaving the sacral 
and coccygeal nerves, as they pass through the sacral canal, unpro- 
tected by the dura. The canal, aside from the nerve trunk, is filled 
with a very loose connective tissue; hence, any local anesthesia injected 
into the sacral canal will readily come in contact with and anesthetize 
the nerves; thus giving us a blocking of the nerves rather than an 
infiltration. As the fluid cannot enter the dura the process is free from 
the dangers of spinal anesthesia. , 

In all cases we have used a solution made by dissolving 5 grams of 
novocain in 1 ounce of distilled water and sterilizing same at time of 
using. As in most cases, the space is relatively large in the adult, the 
full ounce being used. Quinine-urea solution should never be used in 
sacral anesthesia. 

Method of procedure is as follows: With the patient in the prone 
position and the sacral region rendered surgically aseptic, the contour 
of the sacrum is made out and the sacral hiatus is located. A small 
amount of novocain solution is injected into the skin and subcuticular 
tissues. Then, with every thing in readiness for the injection, a sharp 
three-inch needle is steadily pushed through the skin, underlying tissue 
and the dense membrane that closed the hiatus into the canal. The 
needle should penetrate the skin at an angle bringing it as near parallel 
to the sacral canal as is convenient. The entering of the canal can 
be clearly noted, as all resistance to further progress ceases as soon as 
the needle passes through the dense membrane of the hiatus. The 



568 LOCAL ANESTHESIA 

needle is then passed one-half inch further up the canal. This leaves 
the needle a safe distance below the dura, but should spinal fluid 
appear the needle should be slightly withdrawn before injecting the 
solution. Should blood appear, it is caused by entering a vein and the 
needle should also be slightly withdrawn. Everything being satis- 
factory, the syringe is connected and the ounce of solution is injected. 
As the canal is large and relatively empty, the injection should meet 
with no appreciable resistance; nevertheless, the injection should be 
made slowly. Anesthesia should be complete in one-half hour and can 
be relied on to last for three to four hours. The area of anesthesia 
includes all that supplied by the sacral nerves, especially those below 
the first sacral; hence, complete anesthesia of the pelvic cavity and 
its viscera, with the anal area, the area used in sitting, and the external 
genitals. In rectal surgery it allows all the freedom of a general anes- 
thesia without its risk and, as a partial anesthesia persists for some 
time after operation, the postoperative discomfort is practically done 
away with. 

POSTOPERATIVE PAIN. 

When the effects of the local anesthesia wear off the patient begins 
to experience acute pain. As this ordinarily occurs from fifteen to 
forty minutes after the operation, it frequently happens that the 
patient has left the surgeon's office, and as a consequence suffers severe 
pain without relief. 

Partly for the relief of the postoperative pain and partly because 
morphine allays nervousness during the operation and tends to diminish 
shock, it has been our practice to give an injection of morphine (§ to J 
gr.) to all patients operated upon under local anesthesia, except, of 
course, in the case of simple incisions and other small operations not 
apt to be accompanied by an appreciable amount of shock or post- 
operative pain. 

OTHER OPERATIONS. 

In this chapter it has been possible to give the details of only a few 
operations. Almost every minor, and many major operations, may 
be performed under local anesthesia. If the principles of local anes- 
thesia are kept firmly in mind and then correlated with a clear under- 
standing of the nerve supply of the locality to be operated upon, it 
will be fairly easy to formulate a reasonably satisfactory method in 
most cases. Such operations as the removal of benign tumors, the 
ligation of arteries and the removal of skin grafts can be easily carried 
out. 

The description of various other methods of local anesthesia, such 
as intraspinal, intravenous, intra-arterial, etc., as well as the discussion 
of the other synthetic substances now on trial, have been purposely 
omitted as tending to confuse. 

For practical purposes, until further experiment proves the contrary, 
novocain used as above outlined is the safest and best method available 
for local anesthesia. 



CHAPTER XXII. 
SPECIAL MINOR OPERATIONS. 

HYPODERMIC INJECTIONS. 

In giving the large quantities of serum that are now used in certain 
treatments, more care is necessary than in the ordinary hypodermic 
administration of drugs. Great care must be taken in sterilizing the 
syringe and needle. Owing to the size of the needle often used, an 
area free from veins should be selected in order to avoid subcutaneous 
hemorrhage. Care must be taken not to inject the serum directly into 
the circulation. 

To avoid as much pain as possible, an area should be selected some 
distance from the nerve trunks and containing enough loose tissue 
to receive the injection without causing pressure. 

As many of these injections cause considerable local reaction, the 
least used parts of the body should be chosen, such as the outer side of 
the left arm, the abdominal wall, etc. 

INTRAMUSCULAR INJECTIONS. 

Certain drugs are found to give less local reaction and to be more 
rapidly absorbed when injected into the substance of the muscles. 
As the muscles contain large bloodvessels and as the substances injected 
into the muscles are often irritating or contain oils, it is important to 
see that the injection is not made directly into the circulation. This 
can be accomplished by removing the syringe from the needle after 
the needle has been driven into the fleshy portion of the muscle. 
Should the point of the needle be in the lumen of an artery or vein, 
there will be a flow of blood from the needle. If there is no flow of 
blood, the syringe is replaced without changing the position of the 
needle and the injection made. The muscles most commonly used 
for these injections are the gluteus maximus, abdominal, and deltoid. 

INTRAVENOUS INFUSION. 

Intravenous infusion is the process for the direct introduction of a 
large amount of fluid directly into the blood supply through the medium 
of a vein. The solution most often used is the so-called normal saline 
solution made by adding 9 parts of chemically pure sodium chloride 
to 1000 parts of freshly distilled water. Other solutions which have 
been recommended are: 



570 SPECIAL MINOR OPERATIONS 

Ringer's solution: 

Potassium chloride 0.2 gm. 

Sodium bicarbonate 0.2 gm. 

Sodium chloride 0.9 gm. 

Freshly distilled water 1000.0 cc 

Alkaline glucose solution: 

Sodium bicarbonate 0.5 gm. 

Glucose 20 . to 30 . gm. 

Freshly distilled water 1000.0 cc 

In the preparation of these solutions it is important to use freshly 
distilled water and to have the solutions prepared immediately before 
use. However, if the emergency is sufficiently great, filtered water or 
even clear tap water may be used after preliminary sterilization. 

An all-glass irrigating jar is prefered, but an enameled iron douch- 
can or even a soft rubber bag may be used. A piece of rubber tubing 
about four feet long is attached to the jar and in the other end of the 
tube a blunt pointed cannula is inserted. 1 Naturally, the entire 
apparatus should be sterilized before use. The solution should be used 
at about the temperature of 100° F. or slightly warmer. It should 
never exceed 105° F. at the point of introduction into the vein. In 
cold weather and when the patient's temperature is subnormal, it is 
well to keep the temperature in the container nearly 120° F.; while in 
warmer weather and in febrile patients the temperature should not 
exceed 105° F. Owing to the loss of heat while the fluid is passing 
through the tube, the temperature at the point of entrance into the 
blood is, under these conditions, usually 100° to 105° F. An actual 
temperature of 105° F. of the fluid leaving the cannula should never be 
exceeded. 

The container should be hung about twenty inches above the vein and 
the fluid injected over a period of fifteen to thirty minutes. Usually 
about 500 to 1000 cc are injected. If the solution is flowing more 
rapidly than this, the container may be lowered to regulate the flow. 

Method.— A tourniquet is applied just firmly enough to hinder venous 
return but not firmly enough to obliterate the pulse. 2 The choice is 
then made of a superficial vein large enough to permit the introduction 
of the cannula. As the veins at the bend of the elbow are of fair size, 
reasonably constant, and situated close to the skin, this is the site 
usually chosen. After the tourniquet has been applied long enough 
to cause the engorgement of the superficial veins, the skin over the 
selected vein is painted with iodine, a hollow needle is attached to the 

1 Recent experiments would indicate that a certain percentage of the reactions follow- 
ing intravenous infusions and arsphenamine injections is due to the use of new rubber 
tubing. To avoid this it is recommended that every piece of new rubber should be 
boiled for at least thirty minutes in a weak sodium carbonate solution and rinsed well 
with sterile water before it is used for the first time. 

2 The ordinary blood-pressure cuff may be used in place of the tourniquet. The pres- 
sure should approximate the patient's diastolic pressure. 



THE INJECTION OF ARSPHEN AMINE 571 

tubing connected with the container holding the infusion solution, and 
a small amount of the solution is allowed to escape. This removes any 
air that may be present in the needle or tubing. The needle is then 
driven through the skin into the lumen of the vein, the tourniquet is 
removed, and the solution allowed to enter the circulation slowly. 

In some cases requiring infusion the veins are collapsed so that direct 
puncture is difficult or impossible. In these cases the following 
technic should be used. The skin is carefully cleansed as for an 
aseptic operation, and an oblique skin-incision about an inch in length 
is made crossing over the vein. The exposed vein is dissected free, 
usually by blunt dissection, and the points of the dressing-forceps are 
slipped beneath it. Two ligatures of plain gut, each about ten inches 
long, are slipped under the vein about half an inch apart, and the for- 
ceps are removed. The distal ligature is tied and the ends left long 
for the purpose of traction. The vein is now slit longitudinally and the 
cannula is inserted in the proximal direction. During this process it is 
important to see that all the air is expelled from the cannula and the 
tube and that the solution flows freely. After the point of the cannula 
is inserted in the vein the second ligature is tied about the end of the 
cannula in a single knot, thus holding the cannula in place and prevent- 
ing the escape of solution and blood. The tourniquet is now removed 
and the solution allowed to flow into the circulation. When the 
required amount of solution has been given, the knot is loosened, the 
cannula removed, and the proximal ligature tied in a square knot to 
prevent hemorrhage. The ends of both ligatures are then cut, the 
vein is allowed to fall back into the wound, and the skin is sutured. 

THE INJECTION OF ARSPHENAMINE. 

Many complicated instruments have been introduced for the injec- 
tion of arsphenamine and similar drugs, but the operation is essentially 
an intravenous infusion and can be performed with practically the same 
apparatus. As the vein is usually needled, that is a hollow needle is 
passed through the skin directly into the vein, the cannula of the 
infusion-set is replaced by the arsphenamine needle, which is simply an 
aspirating needle about gauge 16. For convenience this needle has 
been modified, so that there are now several different shapes on the 
market, the difference consisting solely of the shape of the end by 
which it is held. Except for this modification which allows for better 
control of the puncture, the ordinary aspirating needle fulfils all 
requirements. The only additional instruments required are a glass 
jar with an opening at the bottom for the connection of a rubber tube 
(the ordinary glass irrigating jar serves admirably), several feet of 
rubber tubing, a glass connecting tube, and a glass of sterile salt 
solution. 

The first part of the operation is similar to the needling of the vein 
in securing blood for a Wassermann test. A ligature is placed about 



572 SPECIAL MINOR OPERATIONS 

the arm so as to obstruct only the venous flow, and the region of the 
bend of the elbow is painted with tincture of iodine (one-half strength) 
and washed with alcohol. The remainder of the apparatus, previously 
sterilized, is assembled by attaching the tubing to the outlet of the jar 
and inserting the glass connecting-tube between two pieces of tubing 
near the lower end. The shorter piece of tubing is to connect with the 
needle and should be about one and a half inches in length. The 
glass tubing is placed near the needle so that the flow may be watched 
and the injection of air-bubbles prevented. The flask of saline and the 
arsphen amine, ready mixed in a graduate, are placed close by on the 
table. 

The operation may now be begun. About four ounces of saline 
are poured into the jar which is held by an assistant, who at the same 
time pinches the tubing near the end to prevent the escape of the fluid. 
The needle is passed into the distended vein in the manner described 
in taking a blood specimen, except that, as it is the object here com- 
pletely to enter the vein with the end of the needle and not merely to 
transfix it as often suffices in the above-mentioned operation, the needle 
is introduced at a more acute angle (about 20°) and the beveled edge 
should be made to enter entirely within the vein. When the blood 
flows freely showing that the vein has been entered, the ligature is 
removed and the tube is attached to the needle. In this maneuver, 
in order to guard against the introduction of air into the circulation, 
the tube should be free of air-bubbles and the saline solution should be 
permitted to run slowly during the process of making the connection. 
During the entire operation the surgeon steadies the needle with the 
left hand which rests on the patient's arm, the right hand being used 
to control the flow through the rubber tube. 

As arsphenamine is extremely irritating when injected directly into 
the tissues and often results in marked induration and even dry gan- 
grene of the tissues, it is important to be certain that the needle is in 
the vein and that none of the fluid is apt to escape into the perivascular 
tissues. It is mainly for this purpose that the saline is used. If the 
jar is held by the assistant about three feet above the vein, the saline 
passes through the needle and into the vein with considerable pressure. 
Should the needle be partly or wholly outside the vein, the subcutaneous 
tissues are distended, the saline causing a localized swelling which is 
easily seen. If this condition is present the injection of arsphenamine 
is contraindicated until the needle is adjusted so that there is no escape 
of fluid. In case the saline shows no evidence of escape into the sub- 
cutaneous tissues, the surgeon allows the infusion to proceed until 
there is only a small amount of saline left in the jar. He then stops the 
flow by pinching the lower part of the tube and directs the assistant to 
pour the arsphenamine mixture into the jar which is again raised, this 
time to a distance of about two feet above the vein. The fluid is 
allowed to flow, the rapidity of the flow being varied when necessary 
by lowering or elevating the jar. Just before the last of the arsphena- 



LUMBAR PUNCTURE 573 

mine solution has entered the vein, more saline (a few ounces) is added 
to the small quantity of solution in the jar, and the mixture is allowed 
to run into the vein. It is important not to allow the jar to become 
empty during the entire operation for this procedure may result in the 
introduction of air into the circulation. 

After the injection, the needle is removed with the right hand and 
pressure is immediately made at the point of puncture with a piece 
of gauze held in the left hand. Subcutaneous escape of blood or solu- 
tion, after the needle is removed, is prevented by pressure for a few 
minutes, followed by a snug bandage kept on for several hours. 

It is not intended here to do more than give the technic of the 
injection. The dangers incident to and consequent upon the adminis- 
tration of this most powerful drug must be fully appreciated before it 
is given. Besides the dangers to the patient, it is necessary to be 
absolutely certain of technic in the preparation of the drug and during 
the operation. If the arsphenamine tube is cracked during transit, the 
oxidation of the arsphenamine may result in poisonous arsenates which 
are extremely toxic. Similar results may occur from the use of too hot 
solutions during the operation, or from allowing the arsphenamine to 
stand for several hours or longer after it has been prepared. During 
the operation it is important always to inject the drug into the vein 
and never into the tissues; to prevent the introduction of air-bubbles 
into the circulation; and to inject the solution slowly enough to avoid 
circulatory embarrassment. The use of freshly distilled water in the 
preparation of saline and arsphenamine solution has been found to 
diminish the frequency of febrile reactions following their use. 1 

While the operation above described can be performed in the phy- 
sician's office, the toxicity of the drug makes it desirable that, whenever 
possible, the operation should be performed either at the patient's 
home or in the hospital, the patient being kept in bed for twenty-four 
hours afterward. 

LUMBAR PUNCTURE. 

Any needle about three inches long may be used, but one of gauge 
No. 15 or No. 19 is the most satisfactory. Special needles can be 
procured from any instrument dealer. 

In making the lumbar puncture the lumbar vertebrae are flexed 
upon themselves as much as possible. When the patient is in a sitting 
position this is easily carried out by having him lean forward and rest 
his elbows on his knees. If the patient is unconscious or delirious, it is 
well to pass a folded sheet behind his neck and around his flexed thighs, 
drawing it tight to hold him steady. 

The operator should wear gloves and use every aseptic precaution. 
A point should be found about half an inch lateral to the median line 
between the third and fourth lumbar spines, and the skin over this 

1 Some of the febrile reactions following arsphenamine are apparently due to the 
use of new rubber tubes, (See foot-note page 570.) 



574 



SPECIAL MINOR OPERATIONS 



area should be cleansed with alcohol and then painted with iodine. If 
the patient is conscious this point may be anesthetized by freezing 
or with novocain. The needle is firmly held and is steadily driven in 
toward the spinal canal taking a slightly upward and mesial course, 
so that it enters the canal in the midline, thus avoiding the vessels. 
If the procedure is carried out with a slow, steady movement of the 
needle the change from the characteristic yielding of the flesh to the 
giving way feeling that always accompanies the entrance of the needle 
into the subarachnoid space will be easily noted. As soon as this is 




Fig. 442. — Necrosis of fourth lumbar vertebra, caused by the lumbar puncture needle 
penetrating the body of the vertebra after passing through infected canal. Same 
organism obtained from abscess of vertebra, as was found in canal. 

felt the stilette is withdrawn from the needle, care being taken to 
keep the needle in a steady position. The spinal fluid will then flow 
slowly or rapidly according to the pressure, the caliber of the needle, 
and the thickness of the fluid. 



INTRAVENOUS MEDICATION. 

Other drugs may be injected directly into the circulation in the same 
manner as arsphenamine, but as most of them are introduced in small 



PARACENTESIS OF THE ABDOMEN 575 

quantities they may usually be injected with a simple hypodermic 
syringe. Some surgeons introduce neoarsphenamine, and even arsphe- 
namine directly into the vein by means of a large syringe. For 
the introduction of drugs, such as digipuratum, where only 1 or 
2 cc are introduced, any glass syringe which may be sterilized by 
boiling is satisfactory. After the arm is prepared in the same 
manner as in securing a blood specimen, the needle on the hypo- 
dermic syringe already filled is introduced into the vein. One or 
two drops of blood will appear in the barrel, indicating that the vein 
has been punctured. The injection is then made and the constriction 
on the arm removed. Pressure on the puncture points prevents 
bleeding. 

PARACENTESIS OF THE ABDOMEN. 

This operation is performed for ascites and consists of draining the 
fluid through a small puncture wound in the abdomen. The usual 
technic is simple and the procedure free from risk. In cases where 
adhesions may be suspected as the result of previous peritonitis, great 
care and judgment must be excised to avoid entering or injuring the 
viscera. 

Before the operation the surgeon should see that the patient's 
bladder is emptied. The operation is most conveniently performed 
with the patient in the sitting position. In a simple case of ascites 
the safest point of entry is in the median line, two to four inches below 
the umbilicus. This area should be painted with iodine, a little novo- 
cain should be injected in both the skin and the deeper tissues, and a 
10 to 12 French gauge trocar and cannula introduced into the peritoneal 
cavity. The trocar is then removed and the fluid is allowed to drain 
off by gravity. 

If a large amount of fluid is present and a larger cannula is found more 
desirable, a small skin incision will promote the ease and safety of the 
procedure. In either case the index finger should be held against the 
side of the cannula one inch from its point to keep the cannula from 
being suddenly passed too deep into the abdominal cavity. If there 
has been a lower abdominal midline incision, a point should be selected 
on the same level as the above puncture wound but well to the outer 
side of the right or left rectus muscle. In cases where a large quantity 
of fluid is being withdrawn, the patient's pulse and general condition 
should be carefully watched. If no fluid flows when the trocar is 
withdrawn, it is probably due to the fact that the cannula has not 
entered the abdominal cavity. Therefore, the trocar should be re- 
placed and the cannula forced through the peritoneum. In some cases 
the flow will suddenly stop while there is still a great deal of fluid in the 
abdomen. This is usually caused by the omentum or the intestines 
floating against the end of the cannula. A change of position will often 
correct this, or a blunt probe may be passed through the cannula to 
hold the viscus away. On withdrawing the cannula a small amount of 



576 SPECIAL MINOR OPERATIONS 

fluid usually trickles from the wound. This soon stops. If the can- 
nula has been large or if an incision has been made it is advisable to 
take a single stitch to close the opening. A dry dressing should be 
applied, and changed as often as it becomes saturated. 




Fig. 443. — Ovarian cyst in patient, aged eighty years, simulating distended bladder. 
Pressure symptoms relieved by inserting cannula and withdrawing fluid. 

HYPODERMOCLYSIS. 

Hypodermoclysis is similar to infusion except that the solutions are 
injected into the subcutaneous tissue instead of into the veins. The 
action is slower than when a vein is employed, but the final results are 
much the same. The cannula in the apparatus is exchanged for a 
hollow needle which is inserted into the loose subcutaneous tissue, 
preferably beneath the breasts or into the tissues of the loin or buttocks. 
The irrigating jar is held about three feet above the needle and the 
fluid is allowed to run slowly into the loose subcutaneous tissues. 
Care must be taken not to cause too great distention of the tissues, 
for this causes pain and may cause sloughing. Usually twenty minutes 
are required for the injection of 250 cc. For this reason two needles 
connected by rubber tubing and a T-tube are used and the injection 
is made at two points. Even then it is difficult to inject more than 
500 or 600 cc. The process causes moderate pain, but may be repeated 
after a few hours if necessary. The puncture wounds after the with- 
drawal of the needles are closed with collodion and require no further 
attention. 

PHLEBOTOMY. 

Phlebotomy is the operation for the extraction of a large quantity 
of blood. The amount withdrawn is usually from eight to sixteen 
ounces. The early steps in the operation are the same as given under 
the method of infusion, including the placing of the ligatures about the 
vein. Following this the vein is nicked, the opening being made 
large enough to allow the blood to flow freely but not large enough to 
sever the vein entirely. When sufficient blood has escaped, the tourni- 



WITHDRAWAL OF BLOOD SPECIMEN 



577 



quet is removed and the ligatures above and below the incision in the 
vein are tied and the ends cut off. The vein is then allowed to drop 
back in the wound and the skin is sutured in the usual manner. Phle- 
botomy and infusion may be combined, if indicated. 

If it is desired to withdraw only a small quantity of blood, the vein 
may be punctured with a hoi low needle and the blood allowed to flow 
into a tube, or it may be withdrawn in a syringe. The technic of 
this method will be described in detail under the method of withdrawing 
blood for a Wassermann reaction. 




Fig. 444. — Administration of normal salt solution. (Findley.) 



WITHDRAWAL OF BLOOD SPECIMEN. 

Many of the serologic tests of the present day require from 10 to 20 cc 
of blood, which must be secured under aseptic precautions. Such tests 
include the Wassermann test, hemolytic tests, blood cultures, tests for 
sugar and urea, and many others. 

In adults the blood may best be secured by means of direct puncture 
of a vein and the withdrawal of the required quantity of blood. The 
steps of this operation are as follows: 

The veins about the elbow, being large and superficial, are usually 
chosen. They are engorged by the application of a single turn of roller 
37 



578 SPECIAL MINOR OPERATIONS 

bandage tied about the lower portion of the arm. This, if tied tightly, 
usually serves to obstruct the venous flow without seriously interfering 
with the arterial. If desired, the same result may be obtained with a 
rubber tourniquet, a stout piece of rubber tubing, or the cuff of the 
blood-pressure apparatus. The area of skin in the region of the vein 
chosen is now painted with iodine and washed with alcohol. A 
previously sterilized hollow needle is taken in the right hand while the 
arm of the patient is grasped with the left, the thumb of the operator's 
hand pressing upon the vein of the patient just distal to the point 
where the puncture is to be made. The needle, held at an angle of 45° 
to the surface of the arm, pointing in the direction of venous flow, and 
with the beveled edge directed toward the vein, is pressed slowly and 




Fig. 445. — Taking blood from the donor. (Lewisohn.) 

steadily through the skin into the vein. At the moment of entrance 
when a drop of blood is seen at the opening in the head of the needle, 
the left thumb is removed and the needle is held steady while the drop- 
ping blood is caught in a sterile test-tube. When sufficient blood is 
secured the ligature about the arm is removed, the needle is withdrawn, 
and pressure with a sterile gauze compress is made at the point of punc- 
ture to prevent hemorrhage into the tissues. A snug bandage is then 
applied which need remain in position only a few hours. 

Should the flow not be at once sufficient, the needle may be pulled 
out a little as it may have passed entirely through the vein, or it may 
be made to take a more acute angle to the vein, which tends to bring 
the lumen of the needle into alignment with that of the vein. 



BLOOD TRANSFUSION 579 

An ordinary Record syringe may be used to secure a specimen of 
blood, the flow being aided by moderate suction upon the piston. In 
this method a smaller needle may be used causing the patient less pain 
at the time of puncture. After withdrawal of the needle, the blood is 
emptied immediately into a sterile test-tube and the syringe and the 
needle are cleansed with cold water. 

In very stout persons it may be necessary to locate the vein by the 
sense of touch, care being taken not to mistake the fascial implantation 
of the biceps, which is felt as a tense cord, for the median basilic vein. 
In very stout persons, in cases of marked anemia, and in patients with 
very low blood-pressure, it may be impossible to introduce the needle 
into the lumen of the vein. In these cases an incision may be made, 
the vein located, and the needle introduced under direct observation. 

In infants, blood for the Wassermann test, the hemolysis test, or for 
other tests where slight contamination is not contraindicated, may be 
obtained by one or more deep punctures in one of the toes, the blood 
being caught directly in the tube. The flow in these cases can be 
considerably augmented by pressure and manipulation of the part. 
For blood cultures which must be secured absolutely free from con- 
tamination, it is usually necessary in infants to resort to open operation 
with direct puncture of the vein. 

BLOOD TRANSFUSION. 

The transfusion of blood from the circulation of one individual to 
the vessels of another has, owing to the improvements in technic, been 
much more frequently resorted to during the last few years. The 
indications are not yet definitely mapped out in spite of the large 
amount of careful study, both clinical and experimental, which the 
subject has recently received. The procedure has been found of defi- 
nite value in the following conditions : 

1. Acute anemia following hemorrhage from whatsoever cause. 

2. In prolonged bleeding seen in hemophilia, melena neonatorum, 
and jaundice. 

3. In carbon monoxide poisoning and other conditions associated 
with the formation of methemoglobin. 

The value of transfusion is less clearly evident but it may be tried 
when the condition is serious and other remedies have proved useless in : 

1. Pernicious anemia. 

2. Severe secondary anemias. 

3. Certain diseases such as scarlatina, variola, typhoid, etc. 

4. Septic conditions with bacteriemia. 

5. The toxemia of pregnancy and possibly certain other toxemias. 

6. Therapeutic measures for the introduction of immune blood in 
infectious diseases. 1 

1 In the epidemic of infantile paralysis in 1916, the attempt was made to control the 
course of serious cases by the injection of the immune blood of patients convalescent from 
the disease. 



580 SPECIAL MINOR OPERATIONS 

It has been said to be contraindicated in purpura and organic heart 
disease. It is not without danger and is certainly contraindicated in 
mild conditions which react well to simpler methods of treatment. 

The donor should be strong and absolutely free from any disease that 
would make his blood dangerous to the recipient, a blood relative being 
chosen when possible. 

Hemolysis and agglutination tests of the donor's blood should be 
made by a competent serologist whenever possible. However, if the 
emergency is great and a close relative such as a brother or sister can 
be secured as donor, these tests may occasionally be omitted. 

During the operation estimation of the pulse and blood-pressure 
together with blood examination of both the recipient and the donor, 
before and after the operation, aid the operator in determining the 
amount of transfusion necessary and the immediate and after-effects 
of the operation. 

The operation itself may be performed by either the direct or the 
indirect method. 

Direct blood transfusion indicates the direct transfer of blood either 
through a short connecting cannula or by direct suture of the vessels. 
Usually the artery of the donor and the vein of the recipient are chosen. 
Carrel's experimental work has shown that, given the required experi- 
ence and the skill, the direct end-to-end anastomosis of bloodvessels 
can be easily performed. Crile's small cannula, which greatly facili- 
tates the connection of the vessels, consists of a small cylinder through 
which the vein is drawn and turned back, forming a cuff, over which 
the artery is drawn and tied in place and the blood allowed to flow; 
the amount being measured by the change in the general symptoms of 
the recipient and the donor. 

Elsberg's cannula is usually given the preference for direct anas- 
tomosis. The cannula is so devised that the two halves may be 
separated in the same manner as the jaws of a monkey-wrench and the 
lumen enlarged or narrowed to meet any given requirements. In 
this method the artery is passed through the cannula and the end is 
cuffed back and held in place by small hooks. The end of the cannula 
is now slipped into a longitudinal slit in the vein and a ligature is placed 
about the vein over the cuffed end of the artery. It is said that 
Elsberg now advises the use of veins in both recipient and donor rather 
than the arterio-venous anastomosis above described. 

Bernheim's tube is a hollow cylinder about three inches long, joined 
in the center and slightly bulbous at each extremity. The separate 
halves of this tube are fixed in the artery of the donor and the vein of 
the recipient. The disadvantage of this method is that the wall of the 
tube serves to narrow the lumen, thus obstructing the flow. There is 
also apt to be considerable coagulation of the blood even when the tube 
is well-lined with parafhne. 

Brewer's tube is a glass tube which serves to connect the two vessels. 
It is open to the same objections as the Bernheim tube. 

All the methods of direct transfusion require considerable skill and 



BLOOD TRANSFUSION 



581 



close attention to technic. In the hands of the originators they have 
all given most satisfactory results, but in the hands of others, due to 
lack of the required skill, the results have been discouraging; and they 
have the further disadvantage, that the amount and the rate of flow 
cannot be estimated. 

In the indirect method, the blood is withdrawn from the donor and 
injected into the vein of the recipient. Its success or failure depends 
upon the non-coagulation of the blood during its transference. Coagu- 
lation may be avoided in one of two ways : 

1. The blood is transferred so rapidly and with so little opportunity 
for coagulation that it is injected before clotting occurs. 

2. The addition to the withdrawn blood of some anticoagulant, 
such as citric acid. 

The Lindeman method depends upon the first principle. Special 
needles are required and the cannula is made to enter the vein without 
the incision of the skin. The blood is withdrawn from the donor and 




Fig. 446. — Simple arrangement of vessel for use with citrated blood. 



immediately injected into the recipient, the cannulas being kept open 
by means of saline injections between the periods of injection of the 
blood. Syringes must be carefully washed after use and the work 
must be done rapidly. Two operators and a skilled assistant are neces- , 
sary; and at the same time considerable experience in the technic is 
required before the operation can be satisfactorily performed. 

In the Curtis-David method the veins are connected to a paraffine- 
lined glass reservoir to which a syringe is attached. The blood is 
drawn into the reservoir by suction and then forced into the vein of the* 
recipient. The advantage of this method is that there is a minimum 
of traumatism of the tissues. Furthermore, by the use of a paraffine- 
lined vessel the coagulation time is greatly prolonged and there is not 
the same necessity for speed. 

The hirudin method (Hooker and Satterlee) is based upon the action 
of hirudin (an extract derived from the buccal glands of the leech) in 
preventing the coagulation of the blood. This may be used in any of 
the indirect methods in order to prevent coagulation during transfusion. 



582 



SPECIAL MINOR OPERATIONS 



In emergency cases a modification of Lindeman's method may be 
tried, using ordinary aspirating needles and Record syringes. A 30 cc 
syringe is filled with saline solution and inserted into the vein of the 
recipient in the same manner as in intravenous medication. As the 
saline is being slowly injected, another operator withdraws between 
20 and 30 cc of blood from the vein of the donor in a similar syringe, in 
the same manner as blood is obtained for a Wassermann reaction or 




Fig. 447. — Arrangement of apparatus for receiving blood from donor. Note the direc- 
tion of the arrows on the pump and compare with the direction of arrows in Fig. 448. 
This arrangement produces a partial vacuum within the bottle. A very small amount 
of vacuum is all that is necessary. (Hoffman and Habein.) 



blood culture. Leaving the needles in place, the syringes are changed 
and the blood removed from the donor is injected into the recipient; the 
empty syringe at the same time being filled from the vein of the donor. 
The second syringeful of blood may be injected after the first, but if a 
third is required, a clean syringe must be at hand, for it is impracticable 
to use a syringe a second time without cleansing. 

Theoretically, there is no limit to the amount of blood which may be 
injected by this method. Practically, two or three syringefuls are the 



BLOOD TRANSFUSION 



583 



maximum. The reasons for this are apparent. The sharp point of 
the needle traumatizes the wall of the vein which tends to induce 
clotting; the sharp point of the needle easily slips out of or through the 
vein, and the narrow lumen of the needle becomes obstructed by small 
piece of clot or tissue. The inner surfaces of the needles and syringe 
may be covered with a thin layer of sterile paraffine, thereby causing 
the coagulation time to be lengthened and making the operation cor- 
respondingly easier. Between each injection of blood, saline can be 
passed through the needle to remove the small amount of blood present 
which is apt to clot and obstruct the needle. 




Fig. 448. — Arrangement of apparatus for injecting blood into the recipient. Note 
the direction of arrows and pump and compare with Fig. 447. This arrangement pro- 
duces positive pressure within the flask. Keeping the manometer between 70 and 100 
mm. gives the most satisfactory flow. (Hoffman and Habein.) 



In patients who are very anemic the vein of the recipient is apt to 
be collapsed, so that its puncture is dim cult or impossible. In these 
cases the needle used may be replaced by a cannula which is inserted 
in the vein exposed by incision. 

Blood to which sodium citrate has been added (0.2 per cent) will not 
coagulate. If blood is collected under aseptic precautions and sodium 
citrate is added in the proportion of two grains to the liter, it may be 



584 SPECIAL MINOR OPERATIONS 

kept in the ice box for several days and, if necessary, transported over 
long distances without injury. When it is desired to administer it, the 
operation is the same as an ordinary intravenous infusion. Owing to 
the fact that this blood is a good culture medium it should be well 
guarded against contamination, cooled quickly after it has been drawn, 
and kept at a low temperature. This necessitates warming it to body 
temperature just before it is administered. The opponents of this 
method and the hirudin method claim that there is a chemical change 
in the blood which is undesirable. Upon theoretical grounds it would 
not be of value in cases where it was desired to influence hemorrhage, 
while it seems to meet all the indications in illuminating gas (carbon 
monoxide) poisoning, chronic anemia, etc. While cases have been 
reported in which the sodium citrate has seemed to give symptoms 
(chiefly diuresis), the small quantities used ordinarily have little or no 
effect. 

The technic of the citrate method is simple. The venous return of 
the donor's arm is obstructed so as to cause prominence of the veins 
and one of the large veins is punctured with a large needle. The blood 
is allowed to flow T into a sterile glass jar containing a 2 per cent solution 
of sodium citrate. For each 10 cc of citrate solution, 90 cc of blood are 
added, making a 0.2 per cent solution. The citrated blood is injected 
into the vein of the recipient by means of gravity. The injection may 
be performed with the same apparatus used for the intravenous injec- 
tion of arsphenamine. 1 

The amount of blood used is usually from 250 to 500 cc at each 
transfusion. In infants 60 to 100 cc are usually sufficient. For the 
best interest of both the recipient and the donor it is desirable to keep 
w T ithin the above limits, unless special indications for a larger quantity 
exist. Even in such cases it seems better that the larger quantity 
should be transfused in two operations, separated by an interval of a 
few hours. 

SKIN-GRAFTING. 

The skin for skin-grafting may be secured from another portion of 
the patient's body; from one or more healthy donors; or from skin 
removed during an aseptic operation. 

In fatal accident cases, skin removed during the first few hours after 
death from subjects having no evidence of disease, may be used 
immediately or after having been kept in sterile saline in the ice box 
for several days or longer. 

The surface to be grafted should show the bright, red surface of a 
healthy granulating wound. As a preliminary treatment the thorough 
rubbing of the surface the day before will remove the superficial detritus, 
and result in a better surface for grafting. Grafts will rarely be suc- 

1 A glass flask with a two-hole rubber stopper may be used to collect the blood without 
exposing it to the air. By means of a two-way pump attached to one of the tubes, suction, 
to facilitate the flow of blood, and pressure, to aid the injection, may be obtained. 



SKIN-GRAFTING 



585 



cessful where the discharge is profuse and purulent, or where the surface 
is gray and sluggish in appearance. Bleeding from the granulating 
surface must be entirely stopped before the grafts are applied. This 
is accomplished by covering the surface with sterile, moist rubber 
tissue which is covered with cotton and bound firmly to the wound. 




Fig. 449. 



-Rapid growth of five small point grafts covering wound made by excision of 
rodent ulcer. Ten days after operation. 



This ordinarily stops any surface bleeding in a few minutes. Where 
the floor of the ulcer is gray or the granulating surface is coarse or 
edematous, the area can usually be prepared to receive the skin-graft 
successfully by the application of a compress saturated with a mixture 
of glycerin and 10 per cent of tincture of iodine. 




Fig. 450. — Same case as that shown in Fig. 449, showing seven spots on upper arm 
where the point grafts were taken. Wound shows size to which they have grown in two 
weeks. 



For the removal of the graft from the living subject a general 
anesthetic is usually desirable. If a local anesthetic is used, as in point 
graft, care should be taken to inject the solution around and beneath 
the area desired and not into the skin itself. 

Three methods of skin-grafting are available. The first of these, 
point graft, is the one most used in minor surgery, and when carried 
out with care is usually successful. Small pieces of the epidermis are 



586 



SPECIAL MINOR OPERATIONS 



removed by picking the skin up on the point of a needle and with a sharp 
scalpel cutting away a piece the size of a grain of wheat, and transferring 
it directly to the denuded area. In this way several hundred grafts 
can be rapidly removed from the anterior aspect of the thigh, care 
being taken to leave an area of normal skin around the points of 
removal . These pieces of epidermis form islands which rapidly enlarge, 
stimulating the surrounding epithelium in its growth to meet them. 

The grafts can successfully be held in place by strapping with strips 
of sterile zinc oxide plaster. This plaster should be left in place for 
from a week to ten days. Sterile dressings may be applied over the 
plaster and may be changed as often as necessary. The area from 
which the skin has been removed should be treated like any other clean 
wound. Deep scrapings from a sterile area, if dusted over a granulating 
area, will take hold and form new centers of epithelial growth. 




Fig. 451. — Sliding Thiersch graft from razor to surface of ulcer. (Freeman.) 

Thiersch Method.— The surface of the body from which the graft is 
to be taken (usually the thigh or arm) is well shaved and cleansed with 
soap and water, followed by alcohol and sterile water. Strong anti- 
septics are to be avoided as they cause a certain amount of tissue 
destruction. With wide, sharp retractors or especially designed skin- 
grafting retractors, if they are available, the skin is put upon the stretch 
and a thin layer of epidermis and part of the papillary layer are removed 
by a sawing movement of a sharp, thin bladed razor. During the 
excision of the graft, the skin and the razor-blade are kept constantly 
moist by a small stream of salt solution which is allowed to trickle 
upon the blade. Without removing the thin layer of skin from the 
razor-blade, it is transferred to the surface to be covered, and the edge 
is held down while the blade is removed. This allows the graft to be 
laid down flat upon the denuded area. All air bubbles beneath the 
graft must be removed by pressing upon the graft with a compress 



SKIN-GRAFTING 



587 



moistened with saline. This process is repeated until the entire granu- 
lating surface is covered. 

The most important element in successful skin-grafting is the after- 
treatment, which requires close attention to detail. After the skin is 
in place, the graft is covered with a coarse network of strips of one-half 
inch thin rubber tussue, which has previously been sterilized by soaking 
in a 1 to 100 solution of bichloride of mercury and then washed with 
sterile salt solution. A gauze compress moistened with salt solution 
is then bandaged over the wound. Where movement of the patient 
is apt to disturb the grafts, it is well to rig up a protective cage which 
will prevent the rubbing of the involved region by clothing during sleep, 
or in any other accidental manner. 

The dressing should be changed ever day or two, care being taken 
not to disturb the grafts. It is not unusual to see grafts that are freely 
movable after six or seven days, finally become attached to the granula- 
tions with most satisfactory results. 




Fig. 452. — Showing how Thiersch grafts should overlap each other and the borders of 

the ulcer. (Freeman.) 

Recently the open-air treatment of grafts has had many advocates. 
It has been recommended to allow the grafts to be exposed to the air 
for the first few hours, until the drying of the serum causes them to 
become securely stuck to the surface; then to dress them with rubber 
tissue and gauze. The complete open-air treatment has also been 
advised, in which the grafted area is left continually exposed. 

Personal experience has led to the conclusion that the combined 
method is best adapted to most cases. Besides the difficulty of pro- 
tecting from injury areas left completely uncovered, the accumulation 
of the discharge about the edges of the graft, tends to dry and this 
finally prevents further discharge. The discharge then accumulates 
beneath the graft and lifts it as the serum lifts the epidermis in the 
formation of a blister. This blister is apt to break in one spot, the 
result being a pocket with a small opening, the contents of which soon 



588 SPECIAL MINOR OPERATIONS 

become purulent. Even the frequent wetting of the surface with 
saline does not entirely prevent this. 

In the combined method, the wound is allowed to remain open during 
two or three hours daily, preferably in the direct rays of the sun, and 
then the rubber tissue and gauze dressing are replaced . By this method 
the grafts become adherent much sooner than by the closed method, 
and the "blistering" of the open method is avoided. As soon as the 
grafts are fairly firmly attached and the discharge has become scanty, 
the rubber tissue may be discarded and the wound dusted with a bland 
powder to prevent the dressing from becoming adherent. 

The resulting grafts acquire sensibility and other nerve functions 
after several months; but, even years afterward, response of the 
grafted skin to certain nerve stimuli may differ from that of the 
surrounding skin. 

Wolfe Method.— In this method the graft consists of the entire 
thickness of the skin removed from one portion of the body and placed 
upon a granulating area. When successful the result is more satis- 
factory than the Thiersch method. 

The method consists of the removal of a piece of skin, roughly the 
size of the area to be covered. The graft should be carefully trimmed 
so as to remove as much as possible of the subcutaneous fat without 
injuring' the true skin. The edges of the area to be covered are fresh- 
ened and the Wolfe graft is carefully sutured in place with fine silk or 
horsehair sutures. A dressing should be applied which holds the graft 
firmly in place without making sufficient pressure to interfere with 
skin nutrition. The wound is dressed as an ordinary operative wound. 
Often the superficial layer of the skin becomes discolored and may be 
picked off with forceps, but the deeper portion survives. If the entire 
graft becomes dark and shows no sign of regeneration after a week, 
it should be removed. 

The Wolfe method is to be preferred in operations for the relief of 
cicatricial contractions and other similar conditions. The graft fails 
to "take" more often than in the Thiersch method. 

A modified form of the Wolfe method is the grafting of the entire 
thickness of the skin by the flap method, which is described under 
Plastic Operations. 



CHAPTER XXIII. 
SURGICAL TECHNIC AND SUPPLIES. 

In the practice of minor surgery the operator should devote the same 
care to the development of an aseptic technic as is required in major 
surgery. 

In the surgical dispensaries of large industrial plants, and in the out- 
patient department of large hospitals, where a great number of patients 
are treated daily, minor surgery should be practised under exactly 
the same conditions as major surgery in a well-organized hospital. 
The surgeons should wear sterile operating gowns; clean and septic 
surgery should be done in separate operating rooms; and all instruments 
and supplies should be handled according to the accepted precepts of 
modern surgical technic. 

It is, however, understood that considerable minor surgery must of 
necessity be performed by casual surgeons and by general practitioners, 
who for practical and economic reasons are unable to obtain the expen- 
sive apparatus and extensive surgical supplies that are required in the 
up-to-date hospitals of today. 

The general practitioner who devotes only a part of his time to 
surgery and who usually does only minor surgery may, by the expense 
of a little time and ingenuity, develop a surgical technic which is 
is sufficient for his purposes and which compares very favorably with 
the so-called "aseptic technic" which is, of course, only relatively 
aseptic. 

THE OPERATING ROOM. 

In selecting an office the physician should, if practicable, choose 
one where he can have a separate room for an operating and dressing 
room. The room need not be large, eight feet long by six feet wide is 
usually sufficient, but it should be clean and well-lighted, preferably 
by natural light. With very little expense the walls may be painted 
with white enamel and the floor covered with white tile. If tiles are 
not available the floor may be made of cement and painted light gray. 
Even in an old house a very satisfactory operating room may be made 
by removing the picture molding and paper from the walls, filling all 
the cracks with plaster-of-Paris and painting the walls and ceiling with 
enamel paint. If the cement floor is impracticable, linoleum may be 
used, but it should be cemented to the floor and carefully fastened 
down at the edges so as to avoid unnecessary dust. Operations may be 
performed in the physician's office but this is unsatisfactory and is to 
be avoided if possible, 



590 



SURGICAL TECHNIC AND SUPPLIES 



The operating room should contain the following: A wash basin 
with hot and cold water; a white metal examining table; a small glass 




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and metal table; a white enamel chair; an instrument sterilizer; a stool; 
and a small cabinet for instruments and dressings. This list may be 
enlarged upon as much as is required by the practice of the particular 



INSTRUMENTS 591 

surgeon, but the above represents fairly well the minimum require- 
ments. The use of white metal furniture and white paint on the walls 
should be insisted upon. Not only does it expose every speck of dust 
and dirt but it also leads the surgeon to adopt unconsciously a technic 
in keeping with the surroundings. 

The use of some method of boiling water for the sterilization of 
instruments is essential. Electricity is most convenient, and very 
satisfactory electric sterilizers are on the market. In the absence of 
electricity, gas, alcohol, or kerosene oil may be used. 

INSTRUMENTS. 

Many operations may be performed with a knife, a pair of scissors, 
a few artery-clamps, and one or two surgical needles. x\n all-glass 
hypodermic, a few tissue forceps, a grooved director, a probe, a needle- 
holder, an exploratory needle and syringe, and some small retractors 
may be added to the above for routine work. Beyond this it is neces- 
sary for the surgeon to decide what particular instruments are required 
for his individual needs. In general it is better to use only a few instru- 
ments and to be skilled in their use, than it is to have a cabinet full of 
instruments which are seldom required and which are consequently 
apt to be unskillfully handled when their use is attempted. A move- 
ment among hospitals for the standardization of surgical instruments 
has been recently instituted. 

Instruments should be protected from rust, dirt, and injury. They 
should be handled carefully and kept in a closet or wrapped in flannel 
when not in use. Unless the cabinet in the operating room is air- 
tight or nearly so, it is better to keep all instruments in another room 
for they are almost certain to collect moisture when instruments are 
boiled. Instruments left in carbolic acid or alcohol for a few hours 
or longer are almost certain to show appreciable rust. It is said that 
instruments may be kept in a solution of crude phenol 3 parts, potash 
soap 3 parts, and water 100 parts, without showing evidence of rust. 

Instruments should be sterilized by boiling for from five to ten 
minutes in water containing about 1 per cent sodium carbonate. The 
alkali tends to prevent rust and to increase the temperature of the 
water. They should not lie directly against the sides or bottom of the 
boiler, for too high a degree of heat injures them. Protection may be 
secured by using a perforated tray or a piece of cloth placed in the 
bottom of the vessel. 

Knives, scissors, and needles are apt to be dulled if boiled for a long 
time. If they are carefully cleaned, sterilization is satisfactory after 
boiling for two minutes, for clean, polished surfaces are unfavorable 
for the lodgment of bacteria. 

Some surgeons sterilize sharp instruments by immersing them in 
alcohol for fifteen minutes or longer. This is less satisfactory than 
boiling and in time causes rust and corrosion of the instruments. 



592 SURGICAL TECHNIC AND SUPPLIES 

Hard rubber articles will be injured if they are boiled. They should 
be soaked for several hours in a solution of bichloride of mercury 
(1 to 1000) or carbolic acid (1 to 20). Glassware and enamel ware 
may be sterilized by boiling but for convenience they are usually 
sterilized by prolonged immersion in bichloride of mercury (1 to 1000) 
All-glass syringes may be sterilized by boiling, but those in which there 
is a leather washer should be soaked for several hours in formaldehyde 
solution, 2 per cent. Rubber gloves may be boiled 1 or sterilized in 
bichloride solution. All instruments or apparatus should be well 
cleaned with soap and water and rinsed in clear water before being 
boiled or placed in solution. 

After use, instruments should be carefully cleaned and dried before 
being put away. Especial care is required to remove all moisture 
about the joints. If instruments are not to be used for some time 
they should be wiped off with a little liquid petrolatum or vaseline. 
When they are to be carried any distance they should be wrapped in 
soft cloth to prevent direct contact one with another. 

Knives and scissors should be kept sharpened at all times. Incisions 
made with sharp knives are much less painful than those made with 
dull instruments. A fine stone, such as is used for honing razors, is 
usually satisfactory for sharpening knives and needles. Scissors, saws, 
curettes, and similar instruments should be sent to the instrument 
makers when they require resharpening. 

SUTURES AND LIGATURES. 

Sutures and ligatures are, in general, made of two classes of material, 
viz., absorbable and non-absorbable. Absorbable sutures are made 
of catgut or tendon and when placed in the tissues become dissolved 
by the body-fluids and disappear. Non-absorbable sutures are made 
of silk, linen, or wire and tend to remain unchanged in the tissues. 
When left in the tissues they generally remain as non-irritating foreign 
bodies and as a rule produce no symptoms, but if infection takes place 
the suture may cause trouble and have to be removed. In time almost 
all non-absorbable sutures show a certain amount of disintergration 
and given sufficient time the material may entirely disappear. 

Catgut.— Catgut is the most commonly used absorbable suture 
material. It varies in size from 00 up to No. 6. In ordinary practice, 
sizes 1 and 2 are most commonly used. Chromicized catgut is catgut 
which has been treated with bichromate of potash or chromic acid 
so that the strands are tougher and less easily absorbed. The absorba- 
bility of chromic catgut depends on the size of the strands and the 
strength of the chromic acid solution. Very fine 00 plain gut is ab- 
sorbed under favorable circumstances in a day or even less. No. 1 plain 
gut is absorbed in a few days, while strongly chromicized No. 2 or 3 

1 In boiling rubber gloves or catheters care should be taken not to allow the rubber 
to come directly in contact with the sides or bottom of the boiler. 



SUTURES AND LIGATURES 593 

gut may persist in the tissues for thirty days or longer. By careful 
adjustment of the technic, catgut may be so prepared as to have a 
fairly definite absorbability in the living tissues. Thus we speak of 
ten-day catgut or twenty-day catgut, etc. 

Catgut is prepared from the intestine of sheep and consequently 
must be prepared very carefully to eradicate completely all bacteria 
and spores. For this reason the sterilization in small quantities is 
expensive and unsatisfactory so that for office surgery it is better to 
secure catgut already sterilized and sealed in glass tubes which are 
broken when a suture is required. There are several very reliable 
supply houses which manufacture catgut in large quantities and 
distribute it to the profession in sealed glass tubes. Before use the 
tube is placed in bichloride solution (1 to 1000), in order to sterilize the 
outside of the glass, and is then broken in a sterile towel. The catgut 
is removed from the tube with sterile forceps. All forms of catgut 
are destroyed by boiling. 

Kangaroo Tendon.— Kangaroo tendon is made from the tail tendon 
of the kangaroo. It is stronger than catgut and is used in bone surgery 
when a very strong suture is desired. It is sterilized in the same manner 
as catgut and is usually chromicized. 

Silk.— Silk is probably, next to catgut, the most generally used suture 
material. It is relatively non-absorbable and is generally used to 
suture the skin. It is, however, used fairly often as a buried suture, 
almost universally for suture of the intestines, and occasionally in 
some other locations. It may be sterilized by boiling for from fifteen 
to twenty minutes, but it may be secured ready sterilized in sealed 
glass tubes, if desired. For emergency use silk is especially valuable, 
for it is always easily obtainable and can be sterilized in a relatively 
short period of time. 

Linen. —Linen may be used in the same manner as silk but the finer 
sizes are not nearly so reliable. The heavier strands are stronger than 
silk. It may be treated with celluloid which makes it much smoother 
(Pagenstecher's thread) . It is non-absorbable and should not be buried, 
except in the peritoneum. It may be sterilized by boiling. 

Silkworm-gut.— Silkworm-gut is prepared from the contents of the 
silk sac of the silkworm. It is very strong and may be sterilized by 
boiling. It is smooth, strong, non-absorbable and non-irritating. 
It is commonly used for deep through-and-through sutures to approxi- 
mate several layers of tissue especially when there is considerable 
tension. 

Silver Wire.— Silver and other metals have been used for sutures 
especially in bone work They are practically non-absorbable and 
frequently have to be removed. The wire may be easily sterilized 
by boiling. 

Horsehair.— Black horsehair from the tail or mane is an excellent 
non-absorbable suture for use in small wounds of the skin. It does 
not absorb serum and is consequently not penetrated by bacteria, as 
38 



594 SURGICAL TECHNIC AND SUPPLIES 

is silk. We have found it especially desirable in wounds about the 
face, where scarring is to be avoided. It may be sterilized by boiling. 

All the above sutures are available ready sterilized in sealed glass 
tubes. In minor surgery such tubes are convenient and not too 
expensive. As the sutures are cut in short lengths there is little waste 
of material. For emergency use a supply of silk, horsehair, and plain 
and chromicized catgut in the medium sizes (Nos. 1 and 2), are all that 
is required. In the rare cases where very heavy catgut is required the 
No. 2 strands may be used double. 

In emergencies where no suture material is available ordinary sewing 
silk may be used after boiling. 

DRESSINGS. 

Dressings are used on wounds to prevent the introduction of infec- 
tion, to absorb discharges, to control hemorrhage, and to serve as a 
protection to the injured area. Any material which is cheap, easily 
sterilized, and capable of absorbing exudates or discharges in the 
manner of cotton or gauze, may be used for dressings. 

Gauze.— This is by all odds the most desirable material for surgical 
dressings. It is practically the same as cheese cloth except that the 
mesh is larger and it is furnished without sizing thus rendering it more 
absorbent. If commercial cheese cloth is used for dressings it should 
be boiled in a 1 per cent solution of carbonate of soda and thoroughly 
rinsed before drying. Gauze may be secured from surgical supply 
houses in 25- or 50-yard rolls, folded lengthwise, so that the roll is 
about four inches wide. A convenient method of using gauze in office 
practice is to cut the folded gauze in convenient sizes and wrap the cut 
gauze in small bundles covered with a piece of closely woven muslin. 
These bundles may be sterilized in a steam sterilizer at a nearby 
hospital. If kept dry and free from dust the bundles will remain sterile 
for weeks or months. When ready for use the bundle is unpinned and 
the gauze sponges or compresses allowed to fall out upon a sterile towel 
without coming in contact with the hands or the outer surface of the 
muslin covering. Another method which is useful in office practice 
is the sterilization of a large number of sponges in a glass jar. The top 
is left loose while the jar of gauze is in the steam sterilizer and is 
screwed down after sterilization is complete. Gauze prepared in this 
manner will remain sterile indefinitely. When a dressing is desired, 
the jar is opened and a sufficient number of gauze squares are removed 
with sterile forceps. Gauze may be sterilized by boiling, but it must 
be used wet and is unsatisfactory except for emergencies. Formerly, 
unsterile gauze dipped in antiseptic solutions was used for wound 
dressings. Such gauze is possibly better than none, but should never 
be used if sterilized gauze is available. 

Medicated gauze is gauze impregnated with an antiseptic. Among 
the various medicated gauzes which have been in use are bichloride 



DRESSINGS 595 

gauze, phenol gauze, iodoform gauze, bismuth gauze, etc. Except 
iodoform gauze, which is a convenient method of applying small 
quantities of iodoform to certain wounds, none of the various medicated 
gauzes is widely used. If medication is desired on the dressing it is 
much better to apply the substance to sterile gauze just before use. 

Cotton.— Absorbent cotton is widely used to replace gauze or to 
supplement a gauze dressing. It is much cheaper than gauze but is 
unsuitable for direct application to the wound, because it absorbs 
rather poorly and becomes easily packed together when wet. It is 
chiefly of value as a protective dressing used in conjunction with gauze. 
Unbleached non-absorbent cotton is used chiefly for the padding of 
splints. Cotton may be sterilized in the same manner as gauze. It is 
occasionally used for sponging purposes, but it is distinctly inferior to 
gauze. 

Other materials have been advocated from time to time. Wool, 
hemp, wood fiber, paper clippings, and many other similar materials 
have been used chiefly for padding of splints or for purposes of protec- 
tion. They are useful in emergencies, but under ordinary circum- 
stances they are rarely used. 

Drainage.— The surgeon should be provided with a number of small 
soft rubber tubes for drainage purposes. They should be of various 
sizes from about the size of a No. 10 F. catheter to the size of a lead 
pencil or slightly larger. This tubing may be cut lengthwise just 
before use and holes may be cut along the tube in order to facilitate 
drainage. Rubber tubes should be well cleaned with soap and water 
and then boiled in 1 per cent sodium carbonate solution for about 
twenty minutes. They may be conveniently kept in alcohol or 
bichloride solution in a large mouthed jar. In an emergency, rubber 
tubes may be wrapped in gauze and boiled with the instruments. Red 
rubber tubes are said to be the best. 

Rubber tissue drains are made by folding a small piece of rubber 
tissue several times. They permit the escape of the discharge along 
the folds of the rubber tissue. They are chiefly used to care for small 
amounts of serous discharge from clean wounds. Larger pieces of 
rubber tissue are sometimes used for covering a wet dressing, either to 
protect the clothes or to keep the dressing wet. Rubber tissue will 
not stand boiling. It may be sterilized in bichloride solution or 
alcohol. 

Gauze drains may be prepared by folding a strip of gauze so that the 
cut edges are turned inward and then sewing the edges so as to prevent 
the unfolding of the strip. This prevents ravelin gs from becoming 
detached. Drains may be made any desired width but ordinarily 
the one-half-inch width fulfils all requirements. Gauze drains, of 
various widths, each consisting of a single strip of cloth with finished 
edges so that raveling is impossible, may be purchased ready sterilized 
in glass tubes. They are convenient for emergency and office surgery. 



596 SURGICAL TECH NIC AND SUPPLIES 

Cigarette drains are made by rolling a wick of gauze in a sheet of 
rubber tissue. The gauze projects slightly beyond the ends of the 
drain. The capillarity of the gauze aids the drainage of thin dis- 
charges and the rubber tissue prevents adhesions. There is also a 
certain amount of drainage around the edges of the drain. 

For the small infected wounds seen so frequently in minor surgery 
we have used a small strip of gauze well smeared with sterile boric 
acid ointment or other similar ointment. This is, in our opinion, the 
best drainage mterial for wounds of this type. The ointment prevents 
adhesions and permits drainage around the drain, not through it. 
The gauze is easily introduced and does not tend to slip out, as does 
rubber tubing. 

Glass tubes, strands of suture material, and rolls of thin rubber are 
sometimes used for drain. 

SURGICAL ACCESSORIES. 

Towels.— A good quality towel made of ordinary dish toweling should 
be used. Towels should be made in small packages of one to three 
towels wrapped in muslin and sterilized in the same manner as gauze. 
For emergencies, the required number of common face towels may be 
boiled with the instruments and used wet. 

Operating Gowns.— Aprons, caps, masks, and gowns should be steri- 
lized under steam pressure in the same manner as gauze and towels. 
If practicable, the surgeon doing minor surgery should always wear a 
sterile gown when operating. If sterile gowns are not obtainable, 
clean, freshly laundered aprons or gowns may be substituted. Opera- 
tions performed in ordinary dusty street clothing are frequently 
infected. Blood-stained gowns, towels, etc., should be soaked for 
several hours in cold water then rinsed in several changes of cold water 
to remove the stains. 

Adhesive Plaster.— A good quality of zinc oxide adhesive plaster 
should be used. Cheaper plasters are almost certain to cause local 
irritation. The skin should be well dried before the plaster is applied 
as moisture destroys the adhesive power. Sterile strips of adhesive 
plaster may be purchased in wax-paper envelopes. They may be used 
for coaptation of small wounds when suture is not considered desirable. 
Moleskin plaster is much firmer than ordinary adhesive plaster. It 
is generally used in the application of extension to fractures. It 
should be warmed with dry heat before being used. Adhesive plaster 
can easily be removed if it is first moistened with ether or gasoline. 

PREPARATION OF THE PATIENT. 

There can be no doubt that the use of iodine is the most satisfactory 
method of skin preparation for minor surgery. The skin is shaved dry 
and the surface to be operated upon, as well as a considerable area of 



OPERATIVE TECH NIC 597 

surrounding skin, is painted with tincture of iodine. In children and 
others with sensitive skins the iodine should be diluted with alcohol 
and used one-half strength. 

When the skin is moist or when there is macroscopic dirt, the area 
should be washed with alcohol before the iodine is applied. The use 
of soap and water before the application of iodine is not advised because 
the soap clogs the mouths of the pores and prevents penetration of the 
iodine. When practicable, the skin may be well scrubbed the day 
before. 

It is hardly necessary to state that in some places tincture of iodine 
is too irritating and cannot be used. In the eye, the conjunctival sac 
should be irrigated with boric acid solution. In the mouth, the teeth 
should be carefully cleaned and a mild antiseptic mouth wash used. 
About the vagina, anus, and genitalia the parts should be shaved, 
washed with soap and warm water, and rinsed with warm saline. 
Iodine may be used but it is apt to blister if used full strength. 

PREPARATION OF THE SURGEON'S HANDS. 

Before operating the surgeon should scrub his hand with soap and 
water, using a soft nail-brush and devoting particular attention to the 
crevices about the nails. The nails should be cut short so as to diminish 
the subungual space which is difficult to clean. The scrubbing should 
be done methodically beginning at one point and gradually working 
over the entire hand. Each finger should be scrubbed, first one side 
then the nail, then the front and back, and finally the other side. The 
time devoted to the scrubbing should be long enough to remove dirt 
and loose epithelium from the entire hand. After rinsing, the hands 
should be soaked in bichloride of mercury solution (1 to 1000) for three 
minutes and then in alcohol, for one minutes. -If this treatment is 
carefully carried out the hands will be practically sterile but during a 
long operation the perspiration is almost certain to carry a considerable 
number of bacteria from the skin follicles. Consequently, it is better 
to use sterile gloves in addition to the scrubbing. 

In dispensary practice and industrial clinics where a large number of 
patients must be dressed in a short time it is advisable to use rubber 
gloves and to wash the gloves in soap and water and bichloride of 
mercury without removing them. In addition care should be taken 
to handle soiled dressings with forceps as much as possible so as to 
diminish the chances of carrying infection. 

OPERATIVE TECHNIC. 

Before the operation is begun the instruments and supplies should 
be systematically arranged so as to be readily available. The instru- 
ments should be removed from the sterilizer and placed on a table so 
that they are within easy reach. In most cases it is better to have 



598 SURGICAL TECHNIC AND SUPPLIES 

the patient lie flat on a table or couch even for small operations because 
in the horizontal position there is less tendency to fainting. Occasion- 
ally troublesome operations, such as tendon suture or dissection of 
adherent glands, require a surgical assistant who is scrubbed up and 
helps during the operation. However, for most minor operations an 
office assistant who has been trained in the general principles of opera- 
tive technic is all that is required. Many operations may be performed 
without any assistance, but this is unwise except in emergencies . What 
may appear to be an exceedingly simple procedure may develop unto- 
ward symptoms with hemorrhage, shock, or other serious complication. 

Anesthesia.— Minor surgery is performed chiefly under local anes- 
thesia. In some very short operations, where only a single incision is 
required, cutaneous sensation may be dulled by preliminary freezing 
with ethyl chloride; and occasionally it may be better to dispense with 
anesthesia entirely. Severe injuries and some operative conditions 
can best be treated under general anesthesia only. Nitrous oxide may 
be used when the operation is of short duration and unsuitable for local 
anesthesia, while ether should be used when a longer period of uncon- 
sciousness is required. Attempts to operate under local anesthesia 
are apt to be unsuccessful in children under twelve years of age. This 
is because the preparations cause the child to be nervous and appre- 
hensive even though he has little pain and he is consequently very 
difficult to control during operation. If ether or gas is required it 
should be given by an assistant who thoroughly understands its use. 
Some surgeons attempt to operate and at the same time oversee the 
administration of the anesthetic. This is a mistake and is apt to lead 
to serious consequences. Unless ether can be given by an assistant 
whose sole duty is its administration it is better to operate under local 
anesthesia or without anesthesia. 

After the patient is ready for operation the surgeon stands between 
the patient and the table of supplies and places sufficient sterile 
towels about the operative field so that there is sufficient room to work 
without fear of contamination. The surgeon should make up his mind 
what he intends to do and then proceed directly to accomplish his 
intention. This is especially true when operating under local anesthe- 
sia. The patient will stand pain better and be much less apprehensive 
if the operation is done carefully and deliberately without waste motion. 
If instruments are dropped, sutures broken, and the surgeon shows 
indecision, the patient becomes increasingly nervous and irritable and 
may actually become uncontrollable. A towel or handkerchief should 
be adjusted so as to obstruct the patient's view of the field of operation 
and the surgeon should devote his time and attention to the operation 
and to nothing else. The habit of talking with an assistant upon a 
subject foreign to the case is apt to lead the patient to believe that the 
surgeon is not especially interested in the work at hand. Remember 
that while the removal of a sebaceous cyst or the suture of a wound 
may be relatively insignificant to the surgeon, they are of great import- 



LIGATURES 599 

ance to the particular patient undergoing operation. Conversation 
with the patient himself which will tend to draw his mind away from 
the fact that he is being operated upon is desirable and should be 
generally cultivated. However, occasionally a patient is seen who 
resents any attempt at conversation, in which case it should be immedi- 
ately discontinued. 

The counting of sponges is not generally required in minor surgery. 
Wounds are rarely so large that every part cannot be inspected. 
Nevertheless, the principle should be kept in mind and when large 
cavities are opened care taken to count every sponge used and to see 
that none is missing when the operation is finished. 

The Incision.— The incision is made with the ordinary scalpel, which 
should be kept sharpened. The scalpel may be held in one of three 
different ways. For incisions, it is held lightly between the thumb and 
fingers as a violinist holds his bow ; for tissue dissection, it is held in the 
same manner as a pen holder; and in cutting cartilaginous or other 
firm tissue it is held as an ordinary table knife. In general the incision 
should be made in the direction of vessels, nerves and muscle fibers 
or the most important of these structures and in such a manner that 
there is no doubt as to the depth of the cut. When in the neighborhood 
of important structures each stroke should be limited in extent, but 
away from such structures a much larger incision may be made with 
each stroke of the knife. The incision should not go forward faster 
than the bleeding can be controlled, and at the end of each stroke the 
wound should be sponged so that the tissues to be incised may be plainly 
seen. Bleeding is controlled by the use of artery-clamps which nip the 
cut end of the vessel and hold it until it can be ligated. 

In the deeper part of the wound the dissection may be conveniently 
made with scissors or even with the blunt handle of the scalpel. In 
going through muscles it is better to separate the fibers by blunt dis- 
section than to divide the fibers transversely. 



LIGATURES. 

During an operation divided arteries and veins should be caught with 
an artery-clamp as soon as cut. If there is an assistant at the opera- 
tion, it is customary to have him apply the clamps, but if the surgeon 
operates alone he must necessarily attend to this detail himself. While 
a small amount of hemorrhage is not dangerous it tends to obscure the 
operative field and thus delays the operation and leads to careless and 
inaccurate surgery. Generally the artery-clamp is applied immediately 
after the vessel is cut. When the surgeon notes that a vessel has been 
divided he immediately makes pressure on the bleeding point either 
with his fingers or a sponge. He then takes a clamp in his hand and 
applies it to the bleeding point as soon as the pressure is removed. To 
do this he often has to include a small amount of tissue near the vessel. 



600 SURGICAL TECH NIC AND SUPPLIES 

If the bite of the clamp has compressed the vessel, bleeding will stop; 
but if bleeding continues, the attempt must be made again. It must 
be remembered that there are two bleeding ends when a vessel is 
divided and consequently, as a rule, two clamps are required. If two 
or more vessels are cut with the same incision several clamps will 
be required. If the cut end of the vessel has retracted beneath the skin 
or fascia, the incision should be enlarged so that the bleeding point 
may be reached. 

After several clamps have been applied they interfere mechanically 
with the operation and should be removed. Very small veins will 
usually stop bleeding from the pressure of the clamp. Slightly larger 
ones may be twisted by turning the clamp three or more times in its 
long axis. This twists the vein and tears the clamp from the tissues 
and is often sufficient to stop the hemorrhage. Ligatures are required 
when these simple measures are insufficient. Plain catgut, size No. 1, 
is used for ligature in almost every location. Occasionally in accident 
cases where a larger artery, such as the brachial, has been cut, it is 
safer to use a double ligature of fairly heavy silk. 

In applying a ligature to a vessel held in a clamp, the clamp is held 
up by the assistant so as to expose the end. A ligature is passed 
around the clamp and tied in a single knot and the loop is slipped down 
so as to be drawn tight below the nose of the clamp. If the assistant 
turns the clamp slightly on its side the knot may be more easily 
tightened without including the end of the instrument. The clamp is 
now removed which permits the knot to be tightened. This must be 
done very carefully in order to avoid pulling the knot from the tissues. 
The second turn of the knot is now tied in a square knot and the excess 
catgut cut away, leaving ends about three-eighths of an inch in length. 
Plain catgut should never be cut shorter than this because the swelling 
of the gut tends to loosen the knot. The ends of silk or chromic gut 
ligatures need not be so long. 

In tying a square, or reef, knot, the end of the ligature is first carried 
toward the surgeon and then away from him. If correctly tied, the 
knot holds firmly. The ordinary "granny" knot, tends to become a 
slip-knot if traction is made on one of the loose ends. The surgeons'- 
knot is made by taking an extra turn in the first part of a square knot. 
It is useful when there is tension which causes the first turn to slip. 
The same thing may be accomplished by having an assistant hold the 
first turn with forceps until the second turn is drawn tight. Ligatures 
should be drawn just tight enough to stop the bleeding and to prevent 
the ligature from slipping off, but not so tight as to cut through the 
tissues. Occasionally it is necessary to pass the ligature around the 
vessel with a needle passed through the tissues. This is true especially 
in the scalp and where tough scar-tissue prevents satisfactory applica- 
tion of an artery-clamp. 



SUTURES 



601 



SUTURES. 

In threading a needle, the end of the suture may be cut obliquely so 
as to make it more easily enter the eye of the needle. If the needle is 
held between the middle and ring-fingers of the left hand, the thumb 
and index finger may be used to catch the end of the suture when it is 
passed through the eye. In order to prevent slipping, the suture may 
be tied to the needle with a single knot. 

Deep Sutures. —For deep sutures a curved needle is usually employed, 
while for the skin a straight needle is preferred. In sutures of muscles 
or other soft tissues an ordinary sewing needle may be used; but in 
tougher tissues, such as the skin or heavy fascia, a needle with a cutting 
point is required. Hagedorn needles, which are flattened from side to 
side and sharpened to a point with a cutting edge, are widely used for 
this purpose. Surgical needles, triangular in shape with sharp edges, 
are also extensively used. Smooth needles, similar to the ordinary 
cambric needle, are used for intestinal sutures. When curved they 
may be used for the suture of muscular tissue. To suture a skin- 
incision with an ordinary sewing needle is almost impossible and should 
not be attempted. 

Sutures may be interrupted or continuous. A single thread is 
ordinarily used though in some cases where an especially strong suture 
is needed, the needle may be threaded double so that a double suture 
of silk or catgut is obtained. 



sV w w, jj> V/ 



Fig. 454. — Interrupted sutures; each stitch is knotted separately. (Ashhurst.) 

Interrupted Suture. —The interrupted suture passes through the skin 
about one-half to one centimeter from the margin of the wound, through 
the wound, and out at a similar point on the opposite side. A square 
knot, which must not be directly over the incision but a little to one 
side is tied. 




Fig. 455. — Continuous (overhand) suture. (Ashhurst.) 

Continuous Suture.— A continuous suture is started as an interrupted 
suture but the end is not cut and the suture is continued by a number 
of similar stitches, only the last being tied. Either form of suture 
may be used in a similar manner in muscles or fascia as buried sutures. 
Sutures used for coaptation of tissues should not be tied too tightly, 



602 



SURGICAL TECHNIC AND SUPPLIES 



for tight sutures tend to cut through the tissues and destroy their 
vitality. 

Subcuticular Suture. — A subcuticular suture is a special form of skin- 
suture. Its advantage is that it is buried and there are consequently 
no resulting scars of needle punctures. The suture is started at one 
end of the wound and then passed from one side to the other at a point 
just beneath the skin and finally drawn out of the wound at the other 
end. No knots are tied but the thread is pulled taut, drawing the 
edges of the skin together. In some cases it is not necessary to tie the 
suture, but as a rule it is better to fix the ends either with a small 
perforated lead shot or by means of a single knot tied in each end. 
Catgut, silk, horsehair, or silver wire may be used for a subcuticular 




Fig. 456. — The subcuticular suture; 
it may be used if no dead spaces are 
left in the deeper parts of the wound. 
The needle enters the true skin at each 
bite, not merely the subcutaneous 
tissues. (Ashhurst.) 




Fig. 457. — Chain or lock-stitch. 
(Ashhurst.) 



: » . - U-t-y-','- V-»— l l ^r»J»-»'w»— ■* 



Fig. 458. — Quilt or mattress suture. 
(Ashhurst.) 




Fig. 459. — Figure-of-eight suture, em- 
ployed to unite parietal peritoneum, deep 
fascia and skin. (Ashhurst.) 



suture. Catgut does not require removal. A non-absorbable suture 
is removed by cutting the suture close at one end and then drawing 
it out by a pull in the long direction of the wound. Naturally, sub- 
cuticular sutures are only suitable for straight, clean cut wounds and 
are especially desirable when a large scar is to be avoided. When 
the wound is irregular it is better to use small interrupted sutures. 

Chain Suture. —A chain suture is a continuous suture in which each 
stitch picks up the preceding stitch. The loops pass directly across 
the wound and causes better coaptation. It is frequently used in 
intestinal sutures. 

Mattress Suture.— A mattress suture is made by passing a suture 
through the skin, into the wound and out through the skin on the' 



EMERGENCY MAKESHIFTS 603 

opposite side and then back again into the skin and through the wound 
and out through the skin near the point of origin. If these ends are 
tied the edges of the wound will be drawn together. If desired this 
stitch may be continued as a continuous mattress suture. This form 
of suture is of value when there is considerable tension as it shows little 
tendency to cut through the tissues. 

Approximation Suture.— Approximation sutures are sutures so placed 
as to bring several layers of tissue together. They are frequently 
used before applying skin sutures in order to bring the layers of super- 
ficial tissues together to avoid dead space when the wound is closed. 

All knots in sutures should be square knots. If the second turn is 
made in the same direction as the first a "granny" knot is obtained, 
if in the opposite direction a square knot. It is considered desirable 
to be able to tie the knot with one hand. The maneuver is performed 
as follows: After the stitch is passed, the needle end is taken in the 
right hand and the other end in the left hand in such a manner as to 
cross the ends, the needle end uppermost. Holding the left end 
between the thumb and index finger, the left middle finger is passed 
beneath the loop formed by the crossing of the ends of the suture and 
is hooked upward and flexed so as to catch the end held in the left hand 
in such a manner as to draw it between the tips of the middle and ring- 
fingers, which draw the end through the loop and complete the first 
turn of the knot. The end which has passed through the loop is grasped 
by the thumb and forefinger of the left hand, and the hand is rotated. 
The dorsum of the middle and ring-fingers is placed over the knot, 
with the end of the suture passing over the fingers toward the right. 
The right hand is now crossed to the left so that a second loop is com- 
pleted about the middle and ring-fingers of the left hand. The end of 
the suture held in the left hand is again grasped by the middle and ring- 
fingers and drawn through the loop, completing the knot which is 
drawn taut by the crossed hands. 

Other forms of one-hand knots have been described. They are 
complicated and require considerable practice. In general it is better 
to become proficient in one form of square knot rather than to practise 
a large number most of which will be seldom used. It has been said 
that knots tied with one hand as described above although theoretically 
correct only accidentally result in a square knot, and that most result 
in two half hitches about a straight end. In any event, many one- 
hand knots are very imperfect, and it is not uncommon to see surgeons 
who regularly use this knot add a third hitch for security. Neither of 
the authors of this book uses the one-hand knot. 

EMERGENCY MAKESHIFTS. 

Occasionally the necessity will arise in which an operation must be 
performed with few or no surgical appliances. Ordinarily it is better 
to apply a temporary dressing and delay the operation until surgical 
supplies can be obtained, but if this results in an unreasonable delay 



604 SURGICAL TECHNIC AND SUPPLIES 

it is often possible to make use of substitutes. Considerable ingenuity 
may be exercised in the surgical application of ordinary materials 
which are easily obtainable. 

The question of sterilization is solved by the use of boiling water, 
which is practically always available. A large boiler is used so that 
jars, dishes, and dressings may be thoroughly boiled. Ordinary china 
dishes may be used in place of the enamel trays and solution jars of the 
operating room. 

Towels make admirable substitutes for gauze. The older the towel 
is, the better it serves this purpose. One or more towels which are old 
and thin may be cut up for sponges and compresses. They may be 
sterilized by boiling and used wet or dried in the stove oven. A fairly 
satisfactory method is to do up towels, compresses, and sponges, in a 
single, compact package. This package is forced under the surface of 
the boiling water and allowed to boil for about twenty minutes. If 
the package is made too large or too compact, the water will not pene- 
trate to all parts. 

When the boiling is completed, the package is lifted out of the water 
and allowed to drain for twenty minutes or longer. It is then laid on 
small wooden slats placed across a shallow baking dish and the whole 
put in the oven. The door of the oven should be left open to allow the 
steam to escape freely. The baking dish serves to catch any water 
which drains from the package. If sufficient care is exercised, the 
package may be thoroughly dried in a comparatively short time. As 
the drying process progresses it is necessary to watch the temperature 
of the oven very closely in order to prevent scorching or actual burning 
of the dressing materials. 

Instruments are more difficult to substitute. A razor or a sharp 
pocket-knife may satisfactorily replace the scalpel, but sewing shears are 
rather poor substitutes for surgical scissors. However, if a good firm 
pair, well-sharpened and not too long, is secured, fairly satisfactory 
work may be performed. A pair of tweezers may be used for tissue 
forceps and a small pair of pliers may be used as an hemostatic clamp. 
In using the pliers for this purpose it is naturally impossible to close 
the clamp and lock it so that each vessel must be tied as soon as it is 
clamped. In the absence of any form of clamp, a suture may be passed 
and tied around each bleeding vessel as soon as it is encountered. 
Retractors may be made by bending the handle of a spoon or the tines 
of a fork. Spoons, forks, and wires may be bent so as to form rough 
specula. The ordinary sewing needle may be used for intestinal or 
muscle suture. If a curved needle is desired, a sewing needle should 
be heated to a red heat, bent with pliers, and then dropped in cold 
water. The ordinary needle is ill adapted for suture of the skin. 
Often a small-sized canvas needle or carpet needle may be found in 
dry-goods stores. These usually have a cutting edge similar to a 
surgical needle and pass easily through the skin. A satisfactory 
needle can be made by grinding an edge on a large darning needle. 

Sutures may also be introduced by the use of a sewing-machine 



EMERGENCY MAKESHIFTS 605 

needle which is passed through the skin, threaded, and then withdrawn. 
A pair of heavy pliers makes an excellent needle holder. 

Silk should be used universally for suture material and ligatures 
unless sterilized catgut is available. Silk of a small diameter will 
cause little or no trouble in a clean wound. Cotton and linen may be 
used, but, when available, silk is to be preferred. The thread may be 
sterilized by boiling. 

For the antiseptic treatment of the wound, if tincture of iodine is not 
available it has previously been our custom to use a 50 to 70 per cent 
solution of ethyl alcohol or failing that whiskey or brandy. Under 
prohibition alcohol is difficult to obtain and it will be probably neces- 
sary to limit the treatment of the wound to cleansing measures. We 
have frequently seen excellent results follow thorough scrubbing of 
the wound with soap and water followed by rinsing with large quantities 
of plain boiled water or sterile saline. 

The preparation of the surgeon's hands depends upon the supplies 
available. In the absence of antiseptics, thorough washing of the 
hands will render them nearly sterile. Chloride of lime and carbonate 
of soda (washing soda) may be purchased in most grocery stores. 
If, after the hands are scrubbed, a small amount of each is mixed on the 
hands with a little water, free chlorine, which exerts a powerful anti- 
septic action upon the surface bacteria, results. After five minutes the 
mixture is washed off with sterile water leaving the hands surgically 
clean. 

For irrigations and infusions the ordinary fountain syringe serves 
admirably. It may be wrapped in a towel and thoroughly boiled before 
use. In its absence, a glass jar and piece of rubber tubing may be 
adjusted so as to form a syphon, or a funnel and piece of rubber tubing 
may be used for the same purpose. A substitute for an infusion needle 
is difficult to find. It is usually necessary to cut down upon the vein 
and use a piece of glass tubing such as a glass medicine dropper for a 
cannula when the ordinary hollow needle is not available. 

Many other emergency instruments may be devised. The sharp 
edge of a tin tobacco box may be used as a curette. A poker, heated in 
the fire, serves as a cautery. Carpenters' tools may be used in bone 
work. Several tools commonly used by shoemakers may be adapted to 
surgical uses, and the search of the hardware store or the jeweler's 
repair table may discover an instrument which in an emergency way 
fulfils the special requirement. 

Extemporaneous preparation of instruments and supplies is empha- 
sized not because such makeshifts are desirable, but because every 
surgeon may sooner or later face the need of action under unfavorable 
circumstances and with few supplies. The ingenuity which he exercises 
under these circumstances to make use of the supplies at hand will 
often make for a successful outcome; whereas inaction or suspended 
action may be followed by serious consequences. Surprisingly good 
results will frequently follow attention to asepsis and careful surgical 
technic even when surgical supplies are few and inadequate. 



INDEX. 



Abdomen, bandages of, spiral, 542 

contusion of, 209 

treatment of, 210 

herpes zoster on, 214 

treatment of, 214 

operations on, local anesthesia in, 
560 

paracentesis of, technic of, 575 

wounds of, 211 
Abdominal binder, 545 

wall, desmoid of, 235 
frost-bite of, 38 
Abrasions, 17 

of face, 11,0 

of scalp, 110 

treatment of, 17 
Abscess, acute, 99 

alveolar, 139 

of axilla, 326 

of breast, 219 

cold, aspiration of, 228 

of external genitals of males, 480 

of face, 139 

of hand, 314 

ischiorectal, 458 

of neck, 186 

perirectal, 459 

peritonsillar, 142 

of popliteal space, 402 

retropharyngeal, 143 

supracondylar, 326 

of vulvo-vaginal glands, 510 
Absence of vagina, 507 
Achillodynia, 437 

treatment of, 437 
Acquired deformities of arm, 352 
of foot, 449 
of hazid, 352 
Acromion process of scapula, fracture of, 

247 
Actinomycosis of face, 145 
Adhesions between labia and clitoris, 507 

of prepuce, 479 
Adhesive plaster, preparation of, 596 
Adrenalin as local anesthetic, 552 
Alveolar abscess, 139 

treatment of, 141 
Ambrine in treatment of burns, 35 
Amputation of fingers, traumatic, 299 

of thumb, 302 

of toes, 418 



Amputation of toes, all the toes, 420 
through metatarsus, 420 
with portion of metatarsal bone, 
419 
Anal fissure, 453 

treatment of, 453 
Anesthesia, of foot, complete, 566 
local, 550 

adrenalin in, 552 
application of, methods of, 553 
cocain in, 550 
novocain in, 551 
in operations on abdomen, 560 
on anus, 561 
of blocking intercostal 

nerves, 559 
on face, 556 
on fingers, 562 
on foot, 565 
on hand, 565 
on neck, 558 
on penis, 560, 561 
on scalp, 556 
on scrotum, 560 
of thoracotomy, 558 
on thumb, 564 
postoperative pain in, 568 
technic of, 555 
in minor surgery, technic of, 598 
sacral, 567 
Angina Ludovici, 187 
Angioma of face, 151 
of scalp, 151 
of thigh, 414 
Ankle, fracture about, 368 
sprains of, 398 

symptoms of, 398 
treatment of, 398 
tenosynovitis about, 438 
treatment of, 439 
Anterior metatarsalgia, 436 
Anthrax, 40 

of face, 144 
of foot, 423 
treatment of, 40 
Antiseptics in treatment of infected 

wounds, 90 
Anus, chancroids of, 468 
deformities of, 451 
imperforate, 451 

treatment of, 452 
intertrigo of, 457 

treatment of, 457 



608 



INDEX 



Anus, operations on, local anesthesia in, 
561 
sphincter of, dilatation of, 456 
syphilis of, 468 
tuberculosis of, 468 
tumors of, malignant, 470 
ulcers of, 468 

treatment of, 469 
Approximation sutures, 603 
Arch of foot, external, supports of, 426 
internal, supports of, 426 
transverse, supports of, 426 
Aristol in treatment of infected wounds, 

95 
Arm, arthritis of, tuberculous, 334 
treatment of, 335 
bandages of, broad sling, 547 

triangular, 547 
carcinoma of, 347 
congenital deformities of, 349 
contusions of, 286 
cysts of, sebaceous, 343 
deformities of, acquired, 352 
dislocations of, 247 
erysipelas of, 303 
fractures of, 247 
injuries of, 286 
lawn-tennis, 291 
lipoma of, 341 

treatment of, 342 
muscles of, injuries of, 291 
strain of, 291 

treatment of, 292 
wounds of, 291 
nerves of, injuries of, 289 

treatment of, 290 
neurofibroma of, 340 
neuroma of, 340 
paralysis of, secondary to nerve 

injury, 357 
rodent ulcer of, 347 
sarcoma of, 348 

treatment of, 348 
syphilis of, 338 
tuberculosis of, 334 
tumors of, benign, 340 

malignant, 347 
wounds of, 286 
Arsphenamine, injection of, technic of, 

571 
Arthritis of arm, tuberculous, 334 
of fingers, 332 
gonorrheal, of knee, 392 
of hand, suppurative, 319 

tuberculous, 334 
traumatic, fractures and, 60 
of wrist, gonorrheal, 332 
Artificial pneumothorax, 229 
Aspiration of bladder, 477 

of chest for empyema, 217 

for pleurisy, 215 
of cold abscess, 228 
in treatment of tuberculosis of 
cervical lymph nodes, 198 
Astragalus, fracture of, 375 



Astragalus, fracture of, diagnosis of, 375 

treatment of, 375 
Atresia of hymen, 507 

of urethra, 490 
Atrophy of hand, ischemic muscular, 355 
Axilla, abscess of, 326 

treatment of, 327 
bandages of, figure-of-eight, 528 

triangular, 547 
hygroma of, 342 

treatment of, 343 
lipoma of, 342 
Axillary lymph nodes, tuberculosis of, 
228 



B 



Back, bandages of, figure-of-eight, 542 

triangular, 147 
keloid of, 232 

treatment of, 235 
sprains of, 212 

treatment of, 213 
Balanitis, 478 

treatment of, 478 
Bandages, 518 

of abdomen, spiral, 542 

application of, 519 

of arm, broad sling, 547 

triangular, 547 
of axilla, figure-of-eight, 528 

triangular, 547 
of back, figure-of-eight, 542 

triangular, 547 
Barton's, 526 

of breast, supporting, 543, 544 
of buttock, spica, 534 
of cheek, 526 
of chest, figure-of-eight, 542 

spiral, 542 

triangular, 547 
circular, 519 

of head, 522 

of neck, 523 
Desault's three roller, 529 
of ear, oblique, 524 
of elbow, figure-of-eight, 532 
of eyes, figure-of-eight, 523 

oblique, 523 
figure-of-eight, 520 
of finger, 529 

demi-gauntlet, 530 

gauntlet, 530 
of foot, 537 

triangular, 547 
of forehead, figure-of-eight, 525 
four-tailed, 522, 549 
of groin, spica, 533 

descending, 534 
hammock suspensory, 548 
handkerchief, 547 
of head, 522 

recurrent, 525 
of hip, triangular, 547 



INDEX 



609 



Bandages of knee, 536 
of leg, 537 

of lower extremity, 533 
many-tailed, 544 
of neck, 522 

figure-of-eight, 525 
recurrent, 522 
roller, 518 
of scalp, handkerchief, 548 

triangular, 546 
of scrotum, suspensory, 548 
of shoulder, spica, 527 

descending, 527 
spica, 521 
spiral, 520 

oblique, 520 
reverse, 521 
of stump, recurrent, 541 
T-, 548 
of thigh, 535 
of thumb, spica, 530 
of toes, recurrent, 539 
triangular, 545 
of trunk, 542 
two-tailed T, 548 
of upper extremity, 527, 533 
Velpeau's, 528 
Bandaging, 518 
Barton's bandage, 526 
Bed-sore, 107 

treatment of, 107 
Biceps muscle, rupture of, 292 
treatment of, 293 
Bichloride of mercury in treatment of 

infected wounds, 94 
Bier's hyperemia cups, use of, 82 
Binder, abdominal, 545 

breast, 545 
Bipp in treatment of infected wounds, 95 
Bladder, aspiration of, 477 
Blank-cartridge wounds of hand, 288 
Bleeding in treatment of inflammations, 

84 _ 
Blocking of intercostal nerves, local 

anesthesia in, 559 
Blood specimen, withdrawal of, technic 
of, 576 
transfusion of, 579 
direct, 580 
indirect, 581 
Bloodvessels, injury to, dislocations and, 
68 
rupture of, 30 
wounds of, suture of, 26 
Body of scapula, fracture of 247 
Boils about eye, 134 

of neck, 183 
Bony irregularity in fractures, 46 

spurs on hand, 344 
Boric acid in treatment of infected 

wounds, 94 
Bow-legs, 413 

treatment of, 413 
Brachial plexus, rupture of, 289 
Branchial cysts, 201 

39 



Branchial cysts, treatment of, 202 
Breast, abscess of, 219 

treatment of, 220 
bandages of, supporting, 543, 544 
binder, 545 
hypertrophy of, 225 
tumors of, benign, 224 

treatment of, 224 
Brewer's empyema drainage tubes, 217 
Broad sling bandage of arm, 547 
Bubo, 400 

diagnosis of, 401 
symptoms of, 400 
treatment of, 401 
Burns, 32 

of eyes, 124 
of face, 123 

chemical, 124 
of first degree, 32 
of head, 123 
of mouth, 124 
mustard gas, 125 
of neck, 182 
of penis, 477 
of scrotum, 477 
of second degree, 32 
of third degree, 31 
treatment of, 32 

ambrine in, 35 

bicarbonate of soda in, 32 

carron oil in, 34 

general, 32 

lime water in, 32 

local, 32 ■ 

open air, 35 

picric acid in, 35 

talcum powder in, 32 
Bursitis of hand, 328 

of knee, prepatellar, 392 

suppurative, 396 
olecranon, 310 

treatment of, 310 
pretibial, 397 
subdeltoid, 328 

treatment of, 329 
subgluteal, 397 

of tendon of semimembranosus, 397 
Buttock, bandage of, spica, 534 



Calculi of mouth, 157 

preputial, 479 

of salivary gland, 158 
Callosities of feet, 447 

of hands, 447 
Calomel in treatment of infected wounds, 

95 
Cancer, chimney-sweeps', 500 
Carbolic acid in treatment of infected 

wounds, 93 
Carbuncle of face, 137 

of neck, 184 
Carcinoma of arm, 347 



610 



INDEX 



Carcinoma of hand, 347 
of leg, 415 
of rectum, 471 
of vagina, 516 
of vulva, 516 
Carpal bones, dislocation of, 280 

treatment of, 280 
Carpus, fractures of, 267 
Carrel-Dakin treatment of infected 

wounds, 91 
Catgut sutures, preparation of, 591 
Cellulitis, 96 
of face, 139 
of fingers, end of, 121 

interdigital web of, 323 
of foot, 422 
of forearm, 325 
of hand, 306 
of leg, 400 
of neck, 182 
of scalp, 137 
of thigh, 400 
treatment of, 97 
Cephalhematoma, 111 
Cervical lymph nodes, diseases of, 187 
tuberculosis of, 191 
treatment of, 192 

aspiration in, 198 
heliotherapy in, 

196 
injection in, 198 
passive hypere- 
mia in, 198 
radium in, 198 
roentgen ray in, 

197 
tuberculin in, 193 
vertebra?, dislocation of, 199 
fractures of, 198 

treatment of, 199 
Chain sutures, 602 
Chancre of vagina, 513 

of vulva, 513 
Chancroids of anus, 468 
of vagina, 512 
of vulva, 512 
Charcot's joint of elbow, 339 

of knee, 392 
Chauffeur's fracture of radius, 262 
symptoms of, 265 
treatment of, 267 
Cheek, bandages of, 566 

deformities of, 177 
Chemical burns of face, 124 
Chest, aspiration of, for empyema, 217 
for pleurisy, 215 
bandage of, figure-of-eight, 542 
spiral, 542 
triangular, 547 
contusions of, 208 

treatment of, 209 
keloid of, 232 

treatment of, 235 
wounds of, 211 

treatment of, 211 



Chilblains, 36 

treatment of, 37 
Chimney-sweeps' cancer, 500 
Cicatricial contraction of fingers, 354 

of hand, 354 
Cigarette drain, preparation of, 596 
Circular bandage, 519 
of head, 522 
of neck, 523 
plaster splints, 55 

removal of, 57 
Circumcision in treatment of phimosis, 

493 
Clavicle, dislocation of, 245 
diagnosis of, 245 
treatment of, 245 
fracture of, 237 

treatment of, 238 
Clavus, 446 

treatment of, 446 
Cleft lip, 172 

palate, 175 
Clitoris, hypertrophy of, 506 

treatment of, 506 
Cocain as local anesthetic, 550 

poisoning, treatment of, 551 
Coccygeal cysts, 470 

treatment of, 470 
Coccygodynia, 245, 514 

treatment of, 514 
Coccyx, dislocation of, 246 
treatment of, 246 
fracture of, 245 

treatment of, 245 
Cold abscess, aspiration of, 228 
intense, effects of, 36 
in treatment of inflammations, 83 
Colles' fracture, 261 

treatment of, 262 
Colomba, 176 
Compound dislocations, 69 
fractures, 59 

of finger tip, 298 
Condyloma of vulva, 515 
Congenital deformities of arm, 349 
of foot, 448 
of hand, 349 
dislocations, 72 

sinus of pharyngeal clefts, 157 
stricture of urethra, 490 
Continuous sutures, 601 
Contracted foot, 435 
Contraction of fingers, cicatricial, 354 
Dupuytren's, 352 
of hand, cicatricial, 354 
Volkmann's, 355 
Contused wounds of soft parts, 29 
Contusions of abdomen, 209 
of arm, 286 
of chest, 208 
of ear, 115 
of eye, 112 
of face, 112 
of hand, 286 
of neck, 181 



INDEX 



611 



Contusions of nose, 115 
of penis, 472 
of scalp, 110 
of soft parts, 18 
of testicle, 472 
of trunk, 208 
of ulnar nerve, 291 
Coracoid process of scapula, fracture of, 

247 
Corn, 446 

treatment of, 446 
Coronoid process of humerus, fracture of. 

255 
Costal cartilages, dislocation of, 246 
treatment of, 246 
fracture of, 243 

treatment of, 243 
Cotton dressings, preparation of, 595 
Counter-irritants in treatment of inflam- 
mations, 85 
Cravat of eye, 546 
Crepitus in fractures, 46 
Crest of ilium, fracture of, 244 
Crushing injuries of fingers, 295, 299 
Cuboid, fracture of, 377 
Cuneiform bones, fracture of, 377 
Cupping in treatment of inflammations, 

85 
Cutaneous horns of face, 161 

of scalp, 161 
Cysts, branchial, 201 
coccygeal, 470 
dermoid, of face, 155 

of scalp, 155 
of epididymis, 501 
of mouth, 157 
mucous, 157 
of parotid gland, 158 
of penis, 498 
of scrotum, 500 
sebaceous, of arm, 343 
of face, 152 
of hand, 343 
of scalp, 152 
thyroglossal, 203 
of trunk, 236 
of vagina, 517 
vulvo-vaginal, 511 



D 



Dakin's solution, preparation of, 90 

in treatment of infected 
wounds, 90 
Debridement of wounds, 21 
Decubital gangrene, 107 
Deep suture, 601 

Deformities of arm, acquired, 352 
congenital, 349 
of anus, 451 
of cheeks, 177 

of external genitals of males, 490 
of foot, acquired, 449 
congenital, 448 



Deformities of hand, acquired, 352 
congenital, 349 

of leg, 412 

of rectum, 451 

of thigh, 412 
Deformity in dislocations, 66 
Demi-gauntlet bandage of fingers, 530 
Dermatitis of foot, 441 
Dermoid cysts of face, 155 

of scalp, 155 
Desault's three roller bandage, 529 
Descending spica bandage of groin, 534 

of shoulder, 527 
Desmoid of abdominal wall, 235 
Diabetic gangrene, 106 
Dichloramin-T in treatment of infected 

wounds, 93 
Dilatation of sphincter of anus, 456 
Direct transfusion of blood, 580 
Disarticulation of interphalangeal joint, 
418 

of metatarsophalangeal joint, 418 

of smaller toes, 419 
Dislocations, 64 

of arm, 247 

of carpal bones, 280 

of cervical vertebrae, 199 

of clavicle, 245 

of coccyx, 246 

complications of, 66 

compound, 69 

congenital, 72 

of costal cartilages, 246 

deformity in, 66 

ecchymosis in, 66 

of elbow, 277 

of fibula, 382 

of fingers, 283 

of fourth metatarsal, 382 

fracture and, 68 

function in, restoration of, 72 

habitual, 68 

of hand, 247 

injury to bloodvessels and, 68 

loss of function in, 66 
mobility and, 68 

of lower extremity, 379 

of mandible, 132 

of meniscus, 381 

of metacarpal bones, 281 

of neck, 198 

old, 72 

pain in, 64 

partial, 69 

of patella, 379 

of phalanges of hand, 282 
of thumb, 282 

reduction in, 69 

retention in, 70 

roentgen-ray findings and, 68 

of semilunar bone, 280 

of shoulder, 274 

of sternum, 246 

symptoms of, 62 

swelling in, 66 



612 



INDEX 



Dislocations of tarsus, 382 

tenderness in, 66 

of tendons of hand, 294 
of wrist, 294 

of thumb, 281 

of toes, 381 

treatment of, 69 

of trunk, 237 

of ulnar nerve, 291 

of wrist, 280 
Dorsal vertebrae, fracture of, 244 
Double vagina, 507 
Drainage, 595 

of wounds, 26 
Drains, cigarette, preparation of, 596 

gauge, preparation of, 595 

rubber tissue, preparation of, 595 
Dressings, 594 

cotton, 595 

gauge, 592 

medicated, 594 

of wounds, 27 
Dupuytren's contraction of fingers, 352 



E 



Ear, bandage of, oblique, 522 

contusions of, 115 

drum, rupture of, 115 

external, enlargement of, 176 
plastic surgery of, 176 

foreign bodies in, 119 

furuncle of, 135 

treatment of, 135 

hematoma of, 115 

malposition of, 177 

wounds of, 121 
Ectropion, 172 
Edema of penis, 479 
Elbow, bandage of, figure-of-eight, 532 

Charcot's joint of, 339 

dislocation of, 277 
treatment of, 277 
Embolism of veins, fractures and, 61 
Emergency makeshifts, 603 
Empyema, minor operations for, 217 

aspiration of chest in, 217 
thoracotomy in, 217 
Enlargement of inguinal glands, 400 

of external ear, 176 
Epicondyle of femur, fracture of, 360 
Epididymis, cysts of, 501 

treatment of, 502 
Epididymitis, 481 

treatment of, 482 
Epididymotomy, 482 
Epiphyseal sprain, 261 
Epiphysis of humerus, separation of, 254 

separation of, 49 
Epiplocele, 235 

treatment of, 236 
Epispadias, 496 

treatment of, 496 
Epithelioma of face, 165 



Epithelioma of face, deep seated, 164 
papillary, 165 
superficial, 163 

of lip, 166 

of penis, 499 

of scrotum, 500 

of tongue, 168 

of vagina, 511, 516 

of vulva, 511, 516 
Epulis, 170 

Ergot poisoning, gangrene from, 106 
Erysipelas, 39 

of arm, 103 

of face, 144 

of hand, 303 
Erysipeloid of fingers, 303 

of hand, 303 
Esophagus, wounds of, 181 
Eusol in treatment of infected wounds, 

93 
Exploratory puncture for pleurisy, 215 
External genitals of males, diseases of, 
478 
injuries of, 472 

hemorrhoids, 454 

malleolus of tibia, fracture of, 372 
Eye, bandage of, oblique, 523 

boils about, 134 

contusions of, 114 
treatment of, 115 

cravat of, 546 

foreign body in, 118 

wounds of, 123 
Eyes, bandages of, figure-of-eight, 523 

burns of, 124 



Face, abrasions of, 110 
abscess of, 139 
actinomycosis of, 145 
angiomata of, 151 

treatment of, 151 
anthrax of, 144 
burns of, 121 

chemical, 124 
treatment of, 123 
carbuncle on, 137 
cellulitis of, 139 
chancre of, 146 

treatment of, 146 
contusions of, 114 
cutaneous horns of, 161 

treatment of, 162 
cysts of, dermoid, 155 

diagnosis of, 156 
treatment of, 156 
sebaceous, 152 

diagnosis of, 152 
treatment of, 152, 154 
epithelioma of, 163 
deep seated, 164 

treatment of, 165 
papillary, 165 



INDEX 



613 



Face, epithelioma of, superficial, 163 
treatment of, 164 
treatment of, 165 
radium in, 166 
roentgen ray in, 166 
erysipelas of, 144 
fibroma of, 161 

treatment of, 161 
foreign bodies in, 117 
fractures about, 128 
furnuncles upon, 134 
glanders of, 145 

treatment of, 145 
inflammation of, 133 
lipoma of, 159 

treatment of, 160 
moles of, 150 

treatment of, 150 
operations on, local anesthesia in, 

556 
osteoma of, 160 

treatment of, 160 
papilloma of, 151 
plastic surgery of, 170 
sarcoma of, 169 
septic infections of, 134 
syphilis of, 146 

primary lesion, 146 
secondary lesion, 147 
tertiary lesion of, 147 
tuberculosis of, 148 
tumors of, benign, 159 

malignant, 162 
warts of, 151 
wounds of, 122 

treatment of, 122 
Feet, callosities of, 447 

treatment of, 447 
Felon, 321 

treatment of, 321 
Female genitalia. See Genitalia of 

female. 
Femur, epicondyle of, fracture of, 360 
treatment of, 360 
greater tuberosity of, fracture of, 
359 
treatment of, 360 
lesser trochanter of, fracture of, 360 

treatment of, 360 
neck of, fracture of, 359 

treatment of, 359 
Fibroma of face, 161 
of hand, 340 
of leg, 414 
of penis, 499 
of thigh, 414 
of vagina, 516 
of vulva, 516 
Fibula, dislocations of, 382 
fracture of, 366 
shaft of, fracture of, 366 

treatment of, 367 
Figure-of-eight bandages, 520 
of axilla, 528 
of back, 542 



Figure-of-eight bandages of chest, 542 
of elbow, 532 
of eyes, 523 
of forehead, 525 
of neck, 525 
Finger tip, compound fracture of, 298 
lacerations of, 298 
treatment of, 298 
Fingers, amputation of, traumatic, 299 
treatment of, 299 
arthritis of, 332 

treatment of, 332 
bandages of, 529 

demi-gauntlet, 530 
gauntlet, 530 
contraction of, cicatricial, 354 
treatment of, 354 
Dupuytren's of, 352 
treatment of, 353 
crushing of, 299 
dislocation of, 283 

treatment of, 284 
end of, cellulitis of, 321 

treatment of, 321 
erysipeloid of, 303 

treatment of, 303 
hair follicles of, infection of, 324 
injuries of, crushing, 295 

treatment of, 296 
interdigital web of, cellulitis of, 323 

treatment of, 324 
operations on, local anesthesia in, 

562 
supernumerary, 349 

treatment of, 349 
syphilis of, 338 
web, 350 

treatment of, 350 
Fissure of anus, 453 
Fistula of salivary gland, 159 

urinary, 485 
Fistula-in-ano, 461 
symptoms of, 462 
treatment of, 462 
excision in, 464 
incision in, 462 
Flat-foot, 424 
Flavine in treatment of infected wounds, 

93 
Foot, anesthesia of, complete, 566 
anthrax of, 423 

arch of, external, supports of, 426 
internal, supports of, 426 
transverse, supports of, 426 
bandages of, 537 

triangular, 547 
cellulitis of, 422 
contracted, 435 

treatment of, 435 
deformities of, acquired, 449 

congenital, 448 
dermatitis of, 441 
flat, 424 

symptoms of, 430 
treatment of, 431 



614 



INDEX 



Foot, gangrene of, 443 

treatment of, 444 
hollow, 435 

treatment of, 435 
injuries of, 416 
lymphangitis of, acute, 423 
operations on, local anesthesia in, 

566 
phalanges of, fracture of, 378 

treatment of, 379 
ringworm of, 440 
sprain of, 417 

treatment of, 417 
ulcer of, perforating, 441 

treatment of, 442 
weak, 424 

symptoms of, 430 
treatment of, 431 
wounds of, puncture, 420 
treatment of, 421 
Forearm, bones of, fracture of, 256 
treatment of, 256 
cellulitis of, 325 

treatment of, 325 
in children, bones of, fracture of, 259 

treatment of, 260 
muscles of, wounds of, 291 
Forehead, bandage of, figure-of-eight, 

525 
Foreign bodies in ear, 119 
in eye, 118 
in face, 117 
in head, 117 
in larynx, 120 
in mouth, 119 
in nose, 119 
in penis, 475 
in rectum, 451 
in throat, 119 
in trachea, 120 
in urethra, 510 
in vagina, 510 
Four-tailed bandage, 549 
Fourth metatarsal, dislocation of, 382 
Fractures, 42 

about face, 128 

of acromion process of scapula, 247 
of ankle, 368 
of arm, 247 
of astragalus, 375 
of body of scapula, 247 
of bones of forearm, 256 
in children, 259 
of thumb, 274 
bony irregularity in, 46 
of carpus, 267 
of cervical vertebrae, 198 
chauffeur's, of radius, 262 
of clavicle, 237 
of coccyx, 245 
Colles', 261 
complications of, 59 
compound, 59 

of coracoid process of scapula, 247 
of coronoid process of humerus, 255 



Fractures of costal cartilages, 243 
crepitus in, 46 
of crest of ilium, 244 
of cuboid, 377 
of cuneiforms, 377 
deformity in, 41 
delayed union and, 61 
dislocation and, 68 
ecchymosis in, 43 
embolism of veins and, 61 
of epicondyle of femur, 360 
of external malleolus of tibia, 372 
false point of motion in, 45 
faulty union and, 62 

instrumental correction of, 

62 
manual correction of, 62 
osteotomy for, 62 
of femur, 359 
of fibula, 366 

of finger tip, compound, 298 
function in, restoration of, 58 
of greater trochanter of femur, 359 

tuberosity of humerus, 248 
greenstick, 50 
of hand, 247 
of head of radius, 256 
hemarthrosis and, 60 
hematoma and, 60 
of humerus, 248 
of hyoid bone, 200 
of internal malleolus of tibia, 371 
into frontal sinus, 129 
ischemic contraction and, 60 
of larynx, 200 
of leg, 365 

of lesser trochanter of femur, 360 
loss of function in, 43 
of lower end of tibia, oblique, 372 

extremity, 359 

of humerus, 251 
of malar bone, 129 
of mandible, 130 
of metacarpal bones, 268 
of metatarsal bones, 377 
of nails, 296 
of neck, 198 

of femur, 359 

of scapula, 248 
of nose, 128 

of olecranon process of humerus, 254 
of os calcis, 376 

magnum, 268 
pain in, 42 
paralysis and, 60 
of patella, 361 
of pelvis, 244 
of penis, 473 
of phalanges of foot, 378 

of hand, 271 
Pott's, 368 
of ribs, 241 

roentgenographic control of, 63 
roentgen-ray examination in, 47 
of scaphoid, of foot, 396 



INDEX 



615 



Fractures of scaphoid, of hand, 267 
of scapula, 247 
of semilunar bone, 268 
separation of epiphysis, 49 
of sesamoid bones of foot, 379 

of hand, 272 
of shaft of fibula, 366 

of humerus, 251 
of shoulder, 247 
of skull, 125 

of spinous process of ilium, 245 
spontaneous, 50 
of sternum, 240 
stiffness of muscles and, 61 
of superior maxilla, 130 
of surgical neck of humerus, 249 
of sustentaculum tali, 376 
swelling in, 43 
symptoms of, 42 
of tarsus, 375 
tenderness in, 44 
of thigh, 359 

thrombosis of veins and, 61 
of trachea, 201 
traumatic arthritis and, 60 
treatment of, 50 

metal splints in, 58 

plaster splints in, circular, 55 
preparation of, 54 
removal of, 57 

plaster-of-Paris dressing in, 52 

reduction in, 51 

retention in, 51 

temporary, 51 

Thomas' splint in, 57 

use of splints in, 51 

wooden splint in, 52 
varieties of, 49 
of vertebrae, dorsal, 244 

lumbar, 244 
of zygomatic arch, 130 
Frontal sinus, fracture into, 129 
Frost-bite, 37 

of abdominal wall, 38 
treatment of, 37 
Furuncles of ear, 135 
of nose, 134 
upon face, 134 



G 



Ganglion of wrist, 344 
Gangrene, 102 

decubital, 107 

treatment of, 107 
diabetic, 106 
of foot, 443 

from ergot poisoning, 106 
gas, 108 

symptoms of, 109 

treatment of, 109 
phenol, 106 
senile, 105 

treatment of, 105 



Gangrene, symptoms of, 103 

treatment of, 104 
Gas gangrene, 108 
Gauntlet bandage of finger, 510 
Gauze drains, preparation of, 595 
dressings, preparation of, 594 
Genitalia of female, external, hyper- 
trophy of, 506 
treatment of, 506 
hematoma of, 503 

treatment of, 504 
wounds of, 503 
of males, external, abscess of, 480 
deformities of, 490 
diseases of, 478 
injuries of, 472 
Glanders, 145 
Glycerin in treatment of infected 

wounds, 89 
Gonorrheal arthritis of knee, 392 

of wrist, 332 
Greater trochanter of femur, fracture of, 
359 
tuberosity of humerus, fracture of, 
248 
Greenstick fractures, 50 
Groin, bandages of, spica, 533 
descending, 534 
Gunshot wounds of joints, 79 
Gynecological minor surgery, 503 



H 



Habitual dislocation, 68 
Hair cysts of neck, 201 

follicles of fingers, infection of, 322 
of hand, infection of, 324 
Hallux valgus, 433 

treatment of, 434 
Hammer-toe, 438 

treatment of, 438 
Hammock suspensory bandage, 548 
Hand, abscess of, 314 

arthritis of, suppurative, 319 
treatment of, 319 
tuberculous, 334 

treatment of, 335 
bony spurs on, 344 

treatment of, 122 
bursitis of, 328 
callosities of, 447 

treatment of, 447 
carcinoma of, 347 
cellulitis of, 306 

treatment of, 308 
contraction of, cicatricial, 354 
treatment of, 354 
Volkmann's, 355 

treatment of, 356 

conservative, 356 
preventive, 356 
contusions of, 286 
cysts of, sebaceous, 343 
deformities of, acquired, 352 



616 



INDEX 



Hand, deformities of, congenital, 349 
dislocations of, 247 
erysipelas of, 303 
erysipeloid of, 303 

treatment of, 303 
exostosis of, 344 

treatment of, 344 
fibroma of, 340 

treatment of, 340 
fractures of, 247 
hair follicles of, infection of, 324 
injuries of, 286 

ischemic muscular atrophy of, 355 
treatment of, 356 

conservative, 356 
preventive, 356 
paralysis of, 355 

treatment of, 356 

conservative, 356 
preventive, 356 
myositis of, 355 

treatment of, 356 

conservative, 356 
preventive, 356 
lipoma of, 341 

treatment of, 342 
lymphangitis of, 306 

treatment of, 306 
muscles of, injuries of, 291 
nerves of, injuries of, 289 

treatment of, 290 
neurofibroma of, 340 
neuroma of, 340 
operations on, local anesthesia in, 

565 
osteoma of, 344 

treatment of, 344 
osteomyelitis of, 320 

treatment of, 320 
papilloma of, 343 
paralysis of, secondary to nerve 

injury, 357 
phalanges of, dislocation of, 282 
fracture of, 271 

treatment of, 271 
tuberculosis of, 336 

treatment of, 337 
pyogenic infection of, 305 
ringworm of, 304 

treatment of, 304 
sarcoma of, 348 

treatment of, 348 
skin of, synovial warts of, 346 
treatment of, 347 
syphilis of, 338 
tendons of, dislocations of, 294 

wounds of, 293 
tuberculosis of, 334 
tumors of, benign, 340 

malignant, 347 
warts on, 343 

treatment of, 343 
wounds of, 286 

blank-cartridge, 288 
treatment of, 288 



Handkerchief bandage, 547 

of scalp, 548 
Hands, surgeon's, preparation of, 597 
Harelip, 174 

treatment of, 174 
Head, disfiguring scars of, 172 
bandages of, 522 
circular, 522 
recurrent, 525 
burns of, 123 

treatment of, 123 
foreign bodies in, 117 
injuries of, 110 
of radius, fracture of, 256 

subluxation of, 280 
tumors of, benign, 150 

malignant, 162 
wounds of, 121 
Heat in treatment of inflammations, 86 
Heel, painful, 437 

treatment of, 437 
Heliotherapy in treatment of tubercu- 
losis of cervical lymph nodes, 196 
Hemarthrosis, fractures and, 60 
traumatic synovitis and, 77 
Hematocele, 473 

treatment of, 473 
Hematocolpos, 507 
Hematoma of female genitals, 503 
fractures and, 60 
of leg, 384 
of new-born, 113 
of penis, 473 
of scalp, 111 
of scrotum, 473 
of soft parts, 19 
of thigh, 384 
Hematometra, 507 
Hematosalpinx, 507 
Hemorrhage, control of, 21 
subungual, 297 
of umbilicus, 229 
Hemorrhoids, 453 
external, 454 

treatment of, 452 
internal, 455 

treatment of, 455 
Hernia, umbilical, 229 
Herpes genitalis, 478 

treatment of, 478 
simple, 133 

treatment of, 133 
zoster, 133 

of abdomen, 214 
of thorax, 214 
treatment of, 133 
Hip, bandages of, triangular, 547 
sprains of, 399 

treatment of, 399 
Hollow foot, 435 
Hordeolum, 136 

treatment of, 136 
Horsehair sutures, preparation of, 591 
Humerus, coronoid process of, fracture 
of, 255 



INDEX 



617 



Humerus, coronoid process of, fracture 
of, treatment of, 255 
fractures of, 248 

greater tuberosity of, fracture of, 
248 
treatment of, 249 
lower epiphysis of, separation of, 254 
. treatment of, 254 
extremity of, fractures of, 251 
treatment of, 252 
olecranon process of, fracture of, 254 

treatment of, 254 
shaft of, fracture of, 251 

treatment of, 251 
surgical neck of, fracture of, 249 
treatment of, 250 
Hydrocele, 485 
of labia, 515 
treatment of, 486 
Hydrophobia, 41 
Hygroma of neck, 202 
Hymen, atresia of, 507 
imperforate, 507 
malformation of, 507 
treatment of, 508 
Hyoid bone, fracture of, 200 

treatment of, 200 
Hyperemia, passive, in treatment of 
tuberculosis of cervical lymph nodes, 
198 
Hyperesthesia of vagina, 514 

of vulva, 514 
Hypertonic salt solution in treatment of 

infected wounds, 88 
Hypertrophy of breast, 225 
of clitoris, 506 
of labia minora, 506 
of vulva, 506 
Hypodermic injections, technic of, 569 
Hypodermoclysis, technic of, 576 
Hypospadias, 495 

treatment of, 495 



Ilium, crest of, fracture of, 244 
treatment of, 244 
spinous process of, fracture of, 245 
treatment of, 245 
Imperforate anus, 451 

hymen, 507 
Impetigo contagiosa, 134 
Indirect transfusion of blood, 581 
Infected wounds, 87 
Infection of wounds, prevention of, 21 
Inflammation, 81 

artificial hypermia in, 82 
bleeding in, 84 
cold in, 83 

counter-irritants in, 85 
guaiacol, 86 
ichthyol, 86 
tincture of iodine, 85 
cupping in, 85 



Inflammation of face, 133 
heat in, 86 
leeches in, 85 
of neck, 178 
puncture in, 84 
rest in, 82 
of scalp, 133 
scarification in, 84 
symptoms of, 81 
treatment of, 81 
of umbilicus, 231 
of urethra, 480 
Infusion, intravenous, technic of, 569 
Ingrowing toe-nail, 444 
Inguinal glands, enlargement of, 400 
diagnosis of, 401 
symptoms of, 400 
treatment of, 401 
lymph nodes, tuberculosis of, 228 
Injections of arsphenamine, technic of, 
571 
hypodermic, technic of, 569 
intramuscular, technic of, 569 
in treatment of tuberculosis of 
cervical lymph nodes, 198 
Injuries of arm, 286 

to bloodvessels, dislocations and, 68 
of external genitals of males, 472 
of fingers, crushing, 295 
of foot, 416 
of hand, 286 
of head, 110 
of joints, 62 
of leg, 384 

of median nerve, 289 
of muscles of arm, 291 
of hand, 291 
of leg, 387 
of thigh, 387 
of musculospiral nerve, 289 
of neck, 178 
of nerves of arm, 289 
of hand, 289 
of leg, 387 
of thigh, 387 
of soft parts, 17 

subcutaneous of, 29 
of thigh, 384 
of ulnar nerve, 290 
Instruments, preparation of, 591 
Intercostal nerves, blocking of, local 

anesthesia in, 559 
Interdigital web of fingers, cellulitis of, 

323 
Internal hemorrhoids, 455 

malleolus of tibia, fracture of, 371 
Interphalangeal joint, disarticulation of, 

418 
Interrupted sutures, 601 
Intertrigo of anus, 457 
Intramuscular injections, technic of, 

569 
Intravenous infusion, technic of, 569 

medication, technic of, 574 
Intubation, 181 



618 



INDEX 



Iodoform in treatment of infected 

wounds, 92 
Ischemic muscular atrophy of hand, 355 
paralysis of hand, 355 
myositis of hand, 355 
Ischiorectal abscess, 458 

treatment of, 460 
Itching of vulva, 509 



Joints, injuries of, 64 
sprains of, 72 

abnormal mobility in, 72 
ecchymosis in, 71 
pain in, 73 
swelling in, 73 
symptoms of, 72 
tenderness in, 73 
treatment of, 74 
wounds of, 77 
gunshot, 79 

diagnosis of, 79 
treatment of, 79 



Kangaroo tendon sutures, preparation 

of, 593 
Keloid of tack, 232 

of chest, 232 
Knee, bandages of, 536 

bursitis of, prepatellar, 394 
diagnosis of, 392 
treatment of, 395 
suppurative, 396 

symptoms of, 396 
treatment of, 396 
Charcot's joint, 392 
gonorrheal arthritis of, 392 
loose bodies in, 394 

treatment of, 394 
sprains of, 399 

treatment of, 399 
streptococcic infection of, 393 
synovitis of, acute, 390 

treatment of, 391 
chronic, 391 

treatment of, 392 
tuberculosis of, 393 
Knee-joint, wounds of, 385 
treatment of, 386 
Knock-knee, 413 

treatment of, 412 
Kocher's method of reduction in disloca- 
tion of shoulder, 275 



Labia and clitoris, adhesions between, 
507 
treatment of, 507 



Labia, hydrocele of, 515 

treatment of, 516 
lipoma of, 516 
minora, hypertrophy of, 506 
treatment of, 506 
Lacerated wounds of soft parts, 29 
Lacerations of finger tips, 298 

of perineum, 504 
Larynx, foreign bodies in, 120 
treatment of, 120 
fracture of, 200 

treatment of, 200 
Lawn-tennis arm, 291 

treatment of, 292 
Leeches in treatment of inflammations, 

85 
Leg, bandages of, 537 
carcinoma of, 415 
cellulitis of, 400 
deformities of, 412 
fibroma of, 414 
fractures of, minor, 365 
hematoma of, 384 

treatment of, 384 
injuries of, 384 
muscles of, injuries of, 387 
symptoms of, 387 
treatment of, 388 
nerves of, injuries of, 387 
symptoms of, 387 
treatment of, 388 
osteoma of, 414 
sarcoma of, 414 
tumors of, 414 
ulcer of, chronic, 407 

strapping of, 410 
treatment of, 409 
ambulatory, 409 
general, 409 
by rest in bed, 409 
veins of, phlebitis of, 404 
localized, 406 

treatment of, 407 
postoperative, 404 
treatment of, 406 
thrombosis of, 404 
varicose, 402 

phlebitis of, 406 

treatment of, 406 
treatment of, 404 
Lesser trochanter of femur, fracture of, 

360 
Ligatures, 599 

application of, 600 
preparation of, 592 
Linen sutures, preparation of, 593 
Lip, epithelioma of, 166 

treatment of, 167 
Lipoma of arm, 341 
of axilla, 342 
of face, 159 
of hand, 341 
of labia, 516 
of neck, 206 
of thigh, 414 



INDEX 



619 



Lips, tuberculous ulcers of, 148 
treatment of, 149 
Local anesthesia, 550 
Long extensor of thumb, rupture of, 293 
Loose bodies in knee, 394 
Lower epiphysis of humerus, separation 
of, 254 
extremity of humerus, fracture of, 
251 
Lumbar puncture, technic of, 573 

vertebrae fracture of, 244 
Lupus of vagina, 513 
vulgaris, 148 

treatment of, 149 
of vulva, 513 
Lymph nodes, axillary, tuberculosis of, 
228 
inguinal, tuberculosis of, 228 
Lymphadenitis, 400 
acute, 187 

treatment of, 189 
chronic, 189 

treatment of, 191 
Lymphangitis of hand, 306 



M 

Macrotia, 176 

Malar bone, fracture of, 129 

Male genitalia. See Genitalia of male. 

Malformation of hymen, 507 

of vagina, 507 
Mallet-finger, 295 

treatment of, 295 
Malposition of ear, 177 
Mammary gland, tuberculosis of, 222 

treatment of, 223 
Mandible, dislocation of, 132 
treatment of, 133 
fracture of, 130 

treatment of, 131 
Many-tailed bandage, 544 
Mastitis, chronic lobular, 222 

treatment of, 222 
Mattress sutures, 602 
Maxilla, superior, fracture of, 130 
Mayo's varicose vein enucleator, 403 
Meatotomy, 491 
Median nerve, injury of, 289 
Medicated gauze dressing, 594 
Meniscus, dislocation of, 381 
Metacarpal bones, dislocation of, 281 
Metacarpals, fracture of, 268 
diagnosis of, 270 
treatment of, 270 
Metal splints in treatment of fractures, 

58 
Metartarsal bones, fracture of, 377 
symptoms of, 377 
treatment of, 377 
fourth, subluxation of, 382 
Metatarsalgia, anterior, 436 

treatment of, 437 
Metatarsophalangeal joint, disarticula- 
tion of, 418 



Mobility, abnormal, in sprains of joints, 
72 

loss of, in dislocations, 66 
Moles of face, 150 

of neck, 150 
Molluscum fibrosum, 161 
Morton's disease, 436 

treatment of, 437 
Mouth, burn,s of, 124 

calculi of, 157 

cysts of, 157 

mucous, 157 

foreign bodies in, 119 

tuberculous ulcers of, 148 
treatment of, 149 

wounds of, 122 
Mucous cysts, 157 
Muscles of arm, injuries of, 291 
strain of, 291 
wounds of, 291 

biceps, rupture of, 292 

of forearm, wounds of, 291 

of hand, injuries of, 291 

of leg, injuries of, 387 

rupture of, 30 

stiffness of, fractures and, 61 

strain of, 30 

of thigh, injuries of, 387 

wounds of, suture of, 23 
Muscular atrophy of hand, ischemic, 355 

paralysis of hand, ischemic, 355 
Musculospiral nerve, injury of, 289 
Mustard gas burns, 125 

treatment of, 125 
Myofibroma of vagina, 516 

of vulva, 516 
Myositis of hand, ischemic, 355 
Myxoma of salivary glands, 162 



N 



Nail, fracture of, 296 
Nails, ringworm of, 304 

treatment of, 305 
Nares, plugging of, 117 
Neck, abscess of, 186 

treatment of, 187 
angina Ludovici of, 187 
bandages of, 522 

circular, 523 

figure-of-eight, 525 
boils of, 183 

treatment of, 183 
burns of, 182 
carbuncle of, 184 

treatment of, 185 
cellulitis of, 182 

treatment of, 183 
contusions of, 181 

treatment of, 181 
disfiguring scars of, 172 
dislocation of, 198 
of femur, fracture of, 359 
fractures of, 198 



620 



INDEX 



Neck, hair-cysts of, 201 

treatment of, 201 
hygroma of, 202 

treatment of, 203 
inflammations of, 178 
injuries of, 178 
lipoma of, 206 

treatment of, 207 
moles of, 150 

treatment of, 150 
operations on, local anesthesia in, 

558 
of scapula, fracture of, 248 
septic infection of, 182 
sprains of, 182 

treatment of, 182 
tumors of, 201 
wounds of, 178 

treatment of, 178 
Nerves of arm, injuries of, 289 
of hand, injuries of, 289 
of leg, injuries of, 387 
lesions of, suture of, 24 
median, injury of, 289 
musculospinal, injury of, 289 
of thigh, injuries of, 387 
ulnar, contusion of, 291 
dislocation of, 291 
injury of, 290 
Neurofibroma of arm, 340 

of hand, 340 
Neuroma of arm, 340 

of hand, 340 
New-born, hematoma of, 113 
Nipple, tumors of, 223 

treatment of, 224 
Noma, 108 

treatment of, 108 
Non-tuberculous tenosynovitis, 336 
Nose, contusions of, 115 

treatment of, 115 
foreign bodies in, 119 
fracture of, 128 

treatment of, 128 
furuncles of, 134 
loss of bridge of, 174 

of cartilaginous portion of, 174 
partial loss of ala or tip of, 173 
plastic operations on, 173 
tuberculous ulcers of, 148, 150 
wounds of, 123 
Novocain as local anesthetic, 551 
poisoning, treatment of, 552 



Oblique bandage of ear, 524 
of eye, 523 
fracture of lower end of tibia, 372 
spiral bandage, 520 
Old dislocations, 72 
Olecranon bursitis, 330 

process of humerus, fracture of, 254 
Open air treatment of infected wounds, 
89 



Operating gowns, preparation of, 596 

room, preparation of, 589 
Operative technic, 597 
anesthesia, 598 
incision, 599 
Orchitis, acute, 483 

treatment of, 483 
Os calcis, fracture of, 376 

symptoms of, 376 
treatment of, 376 
magnum, fractures of, 268 
treatment of, 268 
Osteoma of face, 160 
of hand, 344 
of leg, 414 
Osteomyelitis of hand, 320 
Osteosarcoma of skull, 161 
Osteotomy for correction of faulty union 
in fractures, 62 



Paget's disease of nipple, 223 
Painful heel, 437 
Papilloma of face, 151 
of hand, 343 
of penis, 498 
of wrist, 343 
Paracentesis of abdomen, technic of, 575 
Paralysis of arm, secondary to nerve 
injury, 357 
fractures and, 60 
of hand, ischemic muscular, 355 
secondary to nerve injury, 357 
Paraphimoss, 476 

treatment of, 476 
Paronychia, 323 

treatment of, 323 
Parotid gland, cysts of, 158 

tumors of, 170 
Parotitis, suppurative, 143 
Partial dislocations, 69 
Patella, dislocation of, 379 
treatment of, 380 
fracture of, 361 

treatment of, 362 

non-operative, 362 
operative, 364 
meniscus of, dislocation of, 381 
diagnosis of, 381 
treatment of, 381 
Patient, preparation of, for operation, 

596 
Pelvis, fracture of, 244 
Penis, burns of, 477 
contusions of, 472 

treatment of, 473 
cysts of, 498 
edema of, 479 

treatment of, 479 
epithelioma of, 499 

treatment of, 500 
fibroma of, 499 

treatment of, 499 



INDEX 



621 



Penis, foreign bodies in, 475 

treatment of, 475 
fracture of, 473 

treatment of, 473 
hematoma of, 473 

treatment of, 473 
operations on,, local anesthesia in, 

560, 561 
papilloma of, 498 

treatment of, 499 
sarcoma of, 500 
syphilis of, 490 
tuberculosis of, 488 

treatment of, 489 
tumors of, 498 
wounds of, 472 

treatment of, 472 
Perforating ulcer of foot, 441 
Perineum, laceration of, 504 

treatment of, 504 
Perirectal abscess, 459 
Peritonsillar abscess, 142 

treatment of, 142 
Phalanges of foot, fracture of, 378 
of hand, fracture of, 271 
dislocation of, 282 

treatment of, 282 
tuberculosis of, 336 
of thumb, dislocations of, 282 
treatment of, 282 
Pharyngeal clefts, congenital sinus of, 

157 
Phenol, gangrene, 106 
Phimosis, 492 

treatment of, 492 

circumcision in, 493 
Phlebitis of veins of leg, 404 
localized, 406 
postoperative, 404 
Phlebotomy, technic of, 576 
Plantar wart, 447 

treatment of, 448 
Plantaris tendon, rupture of, 388 

treatment of, 389 
Plaster splints, circular, 55 
removal of, 57 
preparation of, 54 
Plaster-of-Paris dressing in treatment of 

fractures, 52 
Plastic surgery of external ear, 176 
of face, 170 
of nose, 173 
Pleurisy, minor operations for, 215 

aspiration of chest in, 215 
exploratory puncture in, 
215 
Plugging of nares, 117 
Pneumothorax, artificial, 229 
Poisoning, ergot, gangrene from, 106 
Polydactylism, 349 

treatment of, 349 
Polypus of rectum, 467 
Popliteal space, abscess of, 402 
Postoperative pain in local anesthesia, 
568 



Postoperative phlebitis of leg, 404 
Pott's fracture, 368 

sequelae of, 372 

treatment of, 369 
Powder grains in skin, 117 
Prepatellar bursitis, 394 
Prepuce, adhesions of, 479 

treatment of, 479 
Preputial calculi, 479 

treatment of, 479 
Pretibial bursitis, 397 
Prolapse of rectum, 465 
Pruritus ani, 458 

treatment of, 458 
vulvae, 509 

treatment of, 509 
Puncture in treatment of inflammations, 
82 
wounds of foot, 420 

of soft parts, 28 
Pyogenic infections of hand, 105 



Quadriceps muscle, rupture of, 389 
symptoms of, 389 
treatment of, 389 



R 



Radium in treatment of epithelioma of 
face, 166 
of tuberculosis of cervical 
lymph nodes, 198 
Radius, chauffeur's fracture of, 264 
head of, fracture of, 256 
subluxation of, 280 
treatment of, 280 
Ranula, 157 

treatment of, 158 
Raynaud's disease, 106 

treatment of, 106 
Rectum, carcinoma of, 471 
deformities of, 451 
foreign bodies in, 451 

treatment of, 451 
polypus of, 467 

treatment of, 467 
prolapse of, 465 

treatment of, 466 
sarcoma of, 471 
syphilis of, 469 
tuberculosis of, 468 
tumors of, malignant, 470 
ulcers of, 468 

treatment of, 469 
wounds of, 450 

treatment of, 450 
Recurrent bandages, 522 
of head, 525 
of stump, 541 
of toes, 539 
Reduction in dislocations, 69 



622 



INDEX 



Retention in dislocations, 70 

of urine, 476 
Retropharyngeal abscess, 143 

treatment of, 143 
Reverse spiral bandage, 521 
Rhinophyma, 173 
Ribs, fractures of, 241 

treatment of, 243 

tuberculosis of, 226 
treatment of, 227 
Ringworm of foot, 440 

of hand, 304 

of nails, 304 

of scalp, 139 
Rodent ulcer, 164 

of arm, 347 
Roentgeno graphic control of fractures, 63 
Roentgen-ray examination of fractures, 47 

findings in dislocatons, 68 

in treatment of epithelioma of face, 
166 
of tuberculosis of cervical lymph 
nodes, 197 
Roller bandages, 518 
Rubber tissue drains, preparation of, 595 
Rupture of biceps muscle, 292 

of bloodvessels, 30 

of brachial plexus, 289 

of ear drum, 115 

of long extensor of thumb, 293 

of muscle, 30 

of nerves, 32 

of plantaris tendon, 388 

of quadriceps muscle, 389 

of tendons, 30 

of triceps tendon, 293 

of urethra, 474 



Sacral anesthesia, 567 
Salivary gland, calculi of, 158 
treatment of, 158 
fistula of, 159 

treatment of, 159 
myxoma of, 162 
Sarcoma of arm, 348 
of face, 169 
of hand, 348 
of leg, 414 
of penis, 500 
of rectum, 471 
of scalp, 169 
of vagina, 517 
of vulva, 517 
Scalds, 32 

treatment of, 32 
Scalp, abrasions of 110 
angiomata of, 151 

treatment of, 151 
bandages of, Handkerchief, 548 

triangular, 546 
cellulitis of, 137 

treatment of, 138 



Scalp, contusions of, 110 
treatment of, 111 
cutaneous horns of, 161 

treatment of, 162 
cysts of, dermoid, 155 

diagnosis of, 156 
treatment of, 156 
sebaceous, 152 

diagnosis of, 152 
treatment of, 152, 154 
hematoma of, 111 

treatment of, 112 
inflammation of, 133 
operations on, local anesthesia in, 

556 
ringworm of, 139 

treatment of, 139 
sarcoma of, 169 
septic infections of, 134 
wounds of, 121 

treatment of, 121 
Scaphoid of foot, fractures of, 376 
treatment of, 377 
of hand, fractures of, 267 
treatment of, 268 
Scapula, acromion process of, fracture of, 
247 
treatment of, 247 
body of, fracture of, 247 

treatment of, 248 
coracoid process of, fracture of, 247 

treatment of, 247 
neck of, fracture of, 248 

treatment of, 248 
winged, 31 
Scarification in treatment of inflamma- 
tions, 84 
Scrotum, bandage of, suspensory, 548 
burns of, 477 
cysts of, 500 
epithelioma of, 500 

treatment of, 501 
hematoma of, 473 
operations on, local anesthesia in, 

560 
tumors of, 500 
Sebaceous cysts of arm, 343 
of face, 152 
of hand, 343 
of scalp, 152 
Semilunar bone, dislocation of, 280 
treatment of, 281 
fracture of, 268 

treatment of, 268 
Senile gangrene, 105 
Septic infections of face, 134 
of neck, 182 
of scalp, 134 
Sesamoid bones of foot, fracture of, 379 

of hand, fractures of, 274 
Shaft of fibula, fractures of, 366 
of humerus, fracture of, 251 
Shoulder, bandages of, spica, 527 
descending, 527 
dislocations of, 274 



INDEX 



623 



Shoulder, dislocations of, treatment of, 
274 
Kocher's method, 275 
fractures about, 247 
Silk sutures, preparation of, 593 
Silkworm gut sutures, preparation of, 593 
Silver sire sutures, preparation of, 593 
Sinus, umbilical, 230 
Skin, grafting of, 584 

Thiersch method of, 586 
Wolfe method of, 588 
of hand, synovial warts of, 346 
powder grains in, 117 
wounds of, suture of, 22 
Skull, fracture of, 125 

osteosarcoma of, 161 
Soft parts, contusions of, 18 
treatment of, 18 
hematoma of, 19 

treatment of, 20 
injuries of, 17 

subcutaneous, 29 
wounds of, 20 
contused, 29 
drainage in, 26 
dressings for, 27 
hemorrhage in, control of, 

21 
infection in, prevention of, 

20 
lacerated, 29 
lavage in, 21 
puncture, 28 
suppurating, 28 
suture of, 22 
treatment of, 29 
antiseptic, 21 
Specific infections, 38 
Sphincter of anus, dilatation of, 456 
Spica bandage of thumb, 531 
of groin, 533 

descending, 534 
of shoulder, 527 

descending, 527 
Spina ventosa, 336 

treatment of, 337 
Spinous process of ilium, fracture of, 245 
Spiral bandages, 520 

of abdomen, 542 
of chest, 542 
oblique, 520 
reverse, 521 
Splints, metal, 58 

plaster, circular, 55 

removal of, 57 
preparation of, 52 
Thomas', 57 

use of, in treatment of fractures, 51 
wooden, 52 
Spontaneous fractures, 50 
Sprain of ankle, 398 
of back, 212 
epiphyseal, 261 
of foot, 417 
of hip, 399 



Sprain of joints, 72 

of knee, 399 

of neck, 182 
Sprain-fracture, 75 
Sternum, dislocation of, 246 
treatment of, 246 

fracture of, 240 

treatment of, 240 
Strain of muscle, 30 
Streptococcic infection of knee, 393 
Stricture of urethra, 484 
congenital, 490 
Stump, bandage of, recurrent, 541 
Sty, 136 

treatment of, 136 
Subcuticular sutures, 602 
Subdeltoid bursitis, 328 
Subgluteal bursitis, 397 
Subungual hemorrhage, 297 

treatment of, 297 
Subluxation, 69 

of fourth metatarsal, 382 

of head of radius, 280 
Sunburn, 36 
Sunlight in treatment of infected wounds, 

89 
Superior maxilla, fracture of, 130 
Supernumerary fingers, 349 

toes, 448 
Supporting bandages of breast, 541, 542 
Suppurating wounds of soft parts, 28 
Suppuration, 87 

of umbilicus, 231 
Suppurative arthritis of hand, 319 

bursitis of knee, 396 

parotitis, 143 

treatment of, 143 

tenosynovitis, 314 
Supracondylar abscess, 326 
treatment of, 326 
Surgeon's hands, preparation of, 597 
Surgical accessories, 596 

adhesive plaster, preparation 

of, 596 
operating gowns, preparation 

of, 596 
towels, preparation of, 596 

neck of humerus, fracture of, 249 
Suspensory bandage, hammock, 548 

of scrotum, 548 
Sustentaculum tali, fracture of, 376 
Suture of bloodvessels, 26 

of muscles, 21 

of nerves, 24 

of tendons, 23 

of wounds, 22 
Sutures, 601 

approximation, 603 

catgut, preparation of, 593 

chain, 602 

continuous, 601 

deep, 601 

horsehair, preparation of, 593 

interrupted, 601 

kangaroo tendon, preparaton of, 591 



624 



INDEX 



Sutures, linen, preparation of, 593 
mattress, 602 
preparation of, 592 
silk, preparation of, 593 
silkworm gut, preparation of, 593 
silver wire, preparation of, 593 
subcuticular, 602 
Syndactylism, 350 

treatment of, 350 
Synovial warts of skin of hand, 346 
Synovitis of knee, acute, 390 
chronic, 391 
traumatic, 75 

hemarthrosis and, 77 
symptoms of, 76 
treatment of, 76 
Syphilis of arm, 338 
of face, 146 

primary lesion, 146 
secondary lesion, 147 
tertiary lesion, 147 
of fingers, 338 
of hand, 338 
of penis, 490 
of rectum, 469 
of testicle, 490 
Syphilitic dactylitis, 339 

treatment of, 339 



Tarsus, dislocation of, 382 

fractures of, 375 
T-bandage, 548 

Tendon sheaths of wrist, tuberculosis of, 
336 
triceps, rupture of, 291 
Tendons of hand, dislocations of, 294 
wound of, 293 
rupture of, 30 
wounds of, suture of, 23 
of wrist dislocations of, 294 
wounds of, 293 
Tenosynovitis about ankle, 438 
non-tuberculous, 336 
treatment of 336 
suppurative 314 

symptoms of, 315 
treatment of, 316 
traumatic, 294 

treatment of, 294 
Testicle, contusions of, 472 
treatment of, 473 
syphilis of, 490 
teratoma of, 501 
tuberculosis of, 489 

treatment of, 489 
tumors of, 500 
undescended, 497 

treatment of, 498 
wounds of, 472 
Tetanus, 39 

treatment of, 39 
Thiersch's method of skin-grafting, 586 



Thigh angioma of, 414 
bandages of, 535 
cellulitis of , 400 
deformities of, 412 
fibroma of, 414 
fracture of, minor, 359 
hematoma of, 384 

treatment of, 384 
injuries of, 384 
lipoma of, 414 
muscles of, injuries of, 387 
symptoms of, 387 
treatment of, 388 
nerves of, injuries of, 387 
symptoms of, 387 
treatment of, 388 
tumors of, 414 
Thomas' splints in treatment of frac- 
tures, 57 
Thoracotomy for empyema, 217 

local anesthesia in, 558 
Thorax, herpes zoster on, 214 

treatment of, 214 
Throat, foreign bodies in, 119 
Thrombosis of veins, fractures and, 61 

of leg, 404 
Thumb, amputation of, 302 
bandage of, spica, 530 
bones of, fracture of, 274 

treatment of, 274 
dislocation of, 281 
long extensor of, rupture of, 293 
operations on, local anesthesia in, 

564 
phalanges of, dislocations of, 282 
Thyroglossal cysts, 203 

treatment of, 202 
Thyroid gland, tumors of, 202 
treatment of, 205 
Tibia, external malleolus of, fracture of, 
372 
treatment of, 372 
internal malleolus of, fracture of, 371 

treatment of, 371 
lower end of, oblique fracture of, 372 
symptoms of, 372 
treatment of, 372 
tubercle of, separation of, 365 
treatment of, 365 
Toe-nail, ingrowing, 444 

treatment of, 444 
Toes, amputation of, 418 

all of the toes, 420 
through metatarsus, 420 
with portion of metatarsal 
bone, 419 
bandages of, recurrent, 539 
dislocation of, 383 
smaller, disarticulation of, 419 
supernumerary, 448 
webbed, 448 
Tongue, epithelioma of, 168 

treatment of, 168 
Tongue-tie, 175 
Towels, preparation of, 596 



INDEX 



625 



Trachea, foreign bodies in, 120 
treatment of, 120 
fracture of, 201 

treatment of, 201 
wounds of, 178 
Tracheotomy, 179 

emergency, 180 
Transfusion of blood, 579 
direct, 580 
indirect, 581 
Traumatic, amputation of fingers, 299 
arthritis, fractures and, 60 
synovitis, 75 
tenosynovitis, 294 
Triangular bandages, 545 
of arm, 547 
of axilla, 547 
of back, 547 
of chest, 547 
of foot, 547 
of hip, 547 
of scalp, 546 
Triceps tendon, rupture of, 293 
Trichophytosis, 304 
capitis, 139 
pedis, 440 
unguium, 304 
Trochanters of femur, fractures of, 359 
Trunk, bandages of, 542 
contusions of, 208 
cysts of, 236 

treatment of, 236 
dislocations of, 237 
fractures of, 237 
tumors of, 232 
wounds of, 211 
Tubercle of tibia, separation of, 365 
Tuberculin in treatment of tuberculosis 

of cervical lymph nodes, 193 
Tuberculosis of anus, 468 
of arm, 334 

of axillary lymph nodes, 228 
of cervical lymph nodes, 191 
of face, 148 
of hand, 334 

of inguinal lymph nodes, 228 
of knee, 393 
of mammary gland, 222 
of penis, 488 

of phalanges of hand, 336 
of rectum, 468 
of ribs, 226 

of tendon sheaths of wrist, 336 
of testicle, 489 
of urethra, 488 
of vagina, 573 
of vulva, 573 
Tuberculous arthritis of arm, 334 
of hand, 334 
ulcers of lips, 148 
of mouth, 148 
of nose, 150 
Tuberosity of humerus, fracture of, 248 
Tumors of arm, benign, 340 
malignant, 347 



Tumors of breast, benign, 224 
of face, benign, 159 

malignant, 162 
of hand, benign, 340 

malignant, 347 
of head, benign, 150 

malignant, 162 
of leg, 414 
of neck, 201 
of nipple, 223 
of parotid gland, 170 
of penis, 498 

of rectum, malignant, 470 
of scrotum, 500 
of testicle, 500 
of thigh, 414 
of thyroid gland, 204 
of trunk, 232 
of vagina, benign, 515 

malignant, 516 
of vulva, benign, 515 

malignant, 516 
Two-tailed T-bandage, 540 



U 



Ulcer of foot, perforating, 441 
rodent, 164 

of arm, 347 
Ulcers of anus, 468 

of leg, chronic, 407 
of rectum, 468 
tuberculous, of lips, 148 
of mouth, 148 
of nose, 150 
of vagina, 512 
of vulva, 512 
Ulnar nerve, contusion of, 291 
dislocation of, 291 
injury of, 290 
Umbilical hernia, 229 

treatment of, 230 
sinus, 230 

treatment of, 231 
Umbilicus, hemorrhage of, 229 
inflammation of, 231 

treatment of, 231 
suppuration of, 231 

treatment of, 231 
surgical diseases of, 229 
Undescended testicle, 497 
Urethra, atresia of, 490 

treatment of, 491 
foreign bodies in, 510 

treatment of, 510 
inflammation of, 480 
rupture of, 474 

treatment of, 474 
stricture of, 484 
congenital, 490 

treatment of, 491 
treatment of, 484 
tuberculosis of, 488 
treatment of, 489 



626 



INDEX 



Urethral caruncle, 517 

treatment of, 517 

Urethritis, 480 

treatment of, 485 

Urinary fistula, 485 

Urine, retention of, 476 



Vagina, absence of, 507 
carcinoma of, 516 

treatment of, 517 
chancre of, 513 

treatment of, 513 
chancroids of, 512 

treatment of, 512 
cysts of, 517 

treatment of, 517 
double, 507 
epithelioma of, 513, 516 

treatment of, 517 
fibroma of, 516 
foreign bodies in, 510 
treatment of, 510 
hyperesthesia of, 514 
treatment of, 514 
lupus of, 513 

treatment of, 513 
malformation of, 507 
treatment of, 508 
myofibroma of, 516 
sarcoma of, 517 

treatment of, 517 
tuberculosis of, 513 

treatment of, 513 
tumors of, benign, 515 

malignant, 516 
ulcers of, 512 
simple, 512 

treatment of, 512 
Vaginismus, 514 

treatment of, 514 
Vaginitis, 508 

treatment of, 509 
Variococele, 487 

symptoms of, 488 

treatment of, 488 

Varicose veins of leg, 402 

phlebitis of, 406 
of vulva, 505 
Veins, embolism of, fractures and, 61 
of leg, phlebitis of, 404 
localized, 406 
postoperative, 404 
thrombosis of, 404 
thrombosis of, fractures and, 61 
varicosed, 402 

phlebitis of, 406 
Velpeau's bandage, 528 
Venereal prophylaxis, 480 

warts of vulva, 515 
Vertebrae, dorsal, fracture of, 244 

lumbar, fracture of, 244 
Volkmann's contracture of hand, 355 



Vulva, carcinoma of, 516 

treatment of, 517 
chancre of, 513 

treatment of, 513 
chancroids of, 512 

treatments of, 512 
condylomata of, 515 

treatment of, 515 
epithelioma of, 513, 516 

treatment of, 517 
fibroma of, 516 
hyperesthesia of, 514 

treatment of, 514 
hypertrophy of, 506 

treatment of, 506 
itching of, 509 

treatment of, 509 
lupus of, 513 

treatment of, 513 
myofibroma of, 516 
sarcoma of, 517 

treatment of, 517 
tuberculosis of, 513 

treatment of, 513 
tumors of, benign, 515 

malignant, 516 
ulceration of, 512 

simple, 512 

treatment of, 512 
varicose veins of, 505 

treatment of, 505 
venereal warts of, 515 

treatment of, 515 
Vulvitis, 508 

treatment of, 509 
Vulvo-vaginal cyst, 511 

treatment of, 512 
glands, abscess of, 510 

treatment of, 510 



W 



Warts of face, 151 

on hand, 343 

plantar, 447 

synovial, of skin of hand, 346 

of vulva, venereal, 515 

on wrist, 343 
Weak-foot, 424 
Webbed toes, 448 
Web-fingers, 350 
Winged scapula, 31 
Wolfe's method of skin-grafting, 588 
Wounds of abdomen, 211 

of arm, 286 

of bloodvessels, suture of, 26 

of chest, 211 

contused, of soft parts, 29 

debridement of, 21 

of ear, 123 

of esophagus, 181 

of eye, 123 

of face, 122 

of female genitals, 503 



INDEX 



627 



Wounds of foot, puncture, 420 
of hand, 286 

blank-cartridge, 288 
of head, 121 
infected, 87 

secondary closure of, 96 
symptoms of, 87 
treatment of, 87 

antiseptics in, 90 
aristol in, 95 

bichloride of mercury in, 94 
bipp in, 95 
boric acid in, 94 
calomel in, 95 
carbolic acid in, 93 
Carrel-Dakin technic of, 91 
Dakin's solution in, 90 
dichloramin-T in, 93 
eusol in, 93 
flavine in, 93 
glycerin in, 89 
hypertonic salt solution, 88 
iodoform in, 94 
open air, 89 
rest in, 88 
sunlight, 89 
infection of, prevention of, 21 
of joints, 77 

gunshot, 79 
of knee-joint, 385 
lacerated, of soft parts, 29 
of mouth, 122 
of muscles of arm, 291 
of forearm, 291 
suture of, 23 



Wounds of neck, 178 

of nerves, suture of, 24 

of nose, 123 

of penis, 472 

puncture, of soft parts, 28 

of rectum, 450 

of scalp, 121 

of soft parts, 20 

suppurating, of soft parts, 28 

of tendons of hand, 291 

suture of, 23 

of wrist, 293 
of testicle, 472 
of trachea, 178 
of trunk, 211 
Wrist, arthritis of gonorrheal, 332 
treatment of, 333 
dislocation of, 280 

treatment of, 280 
ganglion of, 344 

treatment of, 345 
papilloma on, 343 

, treatment of, 343 
tendons of, dislocations of, 294 

sheaths of, tuberculosis of, 336 
treatment of, 336 

wounds of, 293 
warts on, 343 

treatment of, 343 



Zygomatic arch, fracture of, 130 



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